Wiki Referencing an earlier PFSH - Over three years

[Love Coding!]

Hello,

It's been a while since I've been on here and I need a refresher on this. A physician of mine has not seen his patient in over three years, thus making this patient now a "new patient". The physician in his note documents in the PFSH section that "reviewed and unchanged from Jan 12, 2013. Could I count this when calculating his E/M or would a new history had to be obtained because the patient is now in new patient status?

Much appreciated!

Denise

 

[Love Coding!]

Hello,

It's been a while since I've been on here and I need a refresher on this. A physician of mine has not seen his patient in over three years, thus making this patient now a "new patient". The physician in his note documents in the PFSH section that "reviewed and unchanged from Jan 12, 2013. Could I count this when calculating his E/M or would a new history had to be obtained because the patient is now in new patient status?

Much appreciated!

Denise

Any direction would be greatly appreciated

 

[thomas7331]

The E&M documentation guidelines published by CMS don't specifically say that review and update of previous ROS/PFSH is limited to established patients, so I don't think there is anything wrong with allowing this for a new patient visit. The exact wording of the guidelines is as follows:

A ROS and/or a PFSH obtained during an earlier encounter does not need to be re-recorded if there is evidence that the physician reviewed and updated the previous information. This may occur when a physician updates his/her own record or in an institutional setting or group practice where many physicians use a common record. The review and update may be documented by:
- describing any new ROS and/or PFSH information or noting there has been no change in the information; and
- noting the date and location of the earlier ROS and/or PFSH.

Hope this helps some.