Pfsh

[frugalecook1216]

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

 

[Lisa Bledsoe]

They can get "full credit" if the previous PFSH they refer to was complete. They must also note the date of the last PFSH they are referring to.

 

[RebeccaWoodward*]

!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.

http://www.cms.hhs.gov/MLNProducts/Downloads/MASTER1.pdf

 

[frugalecook1216]

If they are indicating the date (October 2008) in the HPI. Is that sufficient.

 

[RebeccaWoodward*]

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…”

 

[frugalecook1216]

Thanks for all you help. I will inform my physicians that in the future they must indicate a date.

 

[FTessaBartels]

2 of 3 areas for established

NOTE that you may have enough to code from just exam and MDM. You only need 2 of 3 areas for an established patient visit.

STILL .. educate the physicians about this because there are times when you need the history to be one of the components for chosing the level of E/M.

F Tessa Bartels, CPC, CPC-E/M