Wiki Please help!! PFSH element requirement for 99214

[mleavitt12]

There is a question in my office about if the following would meet the personal, family and social history requirement for a 99214:

Risk Factors:

Smoked Tobacco Use: Current every day smoker
Cigarettes: Yes -- > 1/2ppd pack(s) per day, Year started: 1983
Smokeless Tobacco Use: Never
Counseled to quit/cut down: yes
Passive smoke exposure: yes
Drug use: no
Caffeine use: 5+ drinks per day
Alcohol use: yes
Drinks per day: social
Seatbelt use: 100 %
Sun Exposure: occasionally

Previous Tobacco Use: Signed On - 12/05/2016
Smoked Tobacco Use: Current every day smoker
Cigarettes: Yes -- > 1/2ppd pack(s) per day, Year started: 1983
Smokeless Tobacco Use: Never
Counseled to quit/cut down: yes
Passive smoke exposure: yes
Drug use: no
Caffeine use: 5+ drinks per day

Previous Alcohol Use: Signed On - 12/05/2016
Alcohol use: yes
Drinks per day: social
Seatbelt use: 100 %
Sun Exposure: occasionally

Please help thanks

 

[thomas7331]

This documentation would count as a social history, 1 history area of the PFSH, which is all that is required for a detailed history assuming you also have an extended HPI and ROS. Then you would just need either a detailed exam or moderate MDM in addition to support a 99214.