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Wiki Credit for PFSH

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dballard2004

dballard2004

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The E/M Guidelines state that if the ROS and/or PFSH is recorded by the ancillary staff or on a form by the patient, the provider must put a notation in the chart that he/she has reviewed this information. Am I correct in assuming that in the absence of the notation, the provider can't be given credit for the PFSH and/or ROS? I would say yes but I'm curious what others think.
 
I would have to agree with you. it goes back to that old standby of "if it's not documented, it's not done."
 
I agree, they have to indicate where the info can be found and that they reviewed it.

Laura, CPC, CEMC
 
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