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Radiology Coding Alert

Reader Questions:

Dig Into Documentation Guidelines for PFSH

Published on Fri Jul 09, 2010

Question:I'm new to E/M coding, and I have a question about past, family, and social history (PFSH). We have new patients sign and date a history form, and the physician reviews the form. Is it OK if the physician's office note includes past and social history but not family history for a new patient?Maine SubscriberAnswer:Your scenario about a new patient visit with documentation of two of three areas (past medical and social) qualifies as pertinent PFSH.How it works: There are three levels of PFSH: none, pertinent, and complete. With no PFSH, you can reach only an extended problem-focused history level, which is associated with 99202 (Office or other outpatient visit for the evaluation and management of a new patient ...).Pertinent: For the PFSH portion of a detailed level of history, you need a pertinent PFSH, which is "a review of the history area(s) directly related to the problem(s) identified in [...]
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