If this is your first visit, be sure to check out the FAQ & read the forum rules. To view all forums, post or create a new thread, you must be an AAPC Member. If you are a member and have already registered for member area and forum access, you can log in by clicking here. If you've forgotten your username or password use our password reminder tool. To start viewing messages, select the forum that you want to visit from the selection below..
When coding an establish visit, in the history section of the HPI. Can a physician wite PFSH since last visit is unchange. Can they get full credit in the history area for this?
Thanks a bunch
!DG: 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 or 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.
If you are going to reference the form, by date, in future notes, I would recommend.......... “ROS, PFSH reviewed from October 1, 2008, no changes, or changes as follows…”