PMFSH documentation requirements for medicare

jbtrueba

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Is it ok to get the PMFSH from ANYWHERE within a chart? For example the discharge notes state the patient is to return back to the nursing home, however nothing was state previously w/i the chart about the patients social history or living in the nursing home. Somebody told me that this would be acceptable because nothing tells us that we can't, but I find it hard to believe.

The purpose of the doctor obtaining the patients past medical, social & family history is, I thought, to help aid in the care of the patient. I don't see how information given in the discharge section would help in the care of the patient and I find it hard to believe that medicare would find this acceptable as well.

I would really like some input on this if anybody can point me in a direction for this answer I would really appreciate it.::confused:
 

RebeccaWoodward*

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

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.


Page 8
 
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The key is PREVIOUS enounter ...

If someone told you that you can code the hospital admit using information that is in the chart AFTER that date of service, they are incorrect (unless it was a specific addendum to the original H&P and noted as such).

But you can refer to previous encounters to complete the PMFSH ... i.e. dates of service BEFORE the date of the admission. Including if the patient was previously admitted and the information was completed at that time. However, the physician must refer to the previous information by date/location in order for it to count. (example: For the PMFSH and ROS please see admission of last week; I reviewed this and there are no changes except as noted in the current HPI.)


F Tessa Bartels, CPC, CPC-E/M
 

jbtrueba

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This particular chart was for outpatient ED

Thank you so much for your reply. Before I forward this information onto my superiors I want to make sure that my situation is clear. This particular chart was for an ER physician in which the chart qualified for a 99285, however according to Medicare guidelines we needed 2 elements w/i the PMFSH. I found that the chart was lacking the 2nd element. I was told that since the doctor stated that the patient was to be discharged back to the nursing facility then we can use that as the 2nd element for social history.

I believe your previous answer will still stand true, but I just want to make sure.
Thank you again!
 
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It's all one visit

If it's an ER visit, it's all ONE visit ... so I would count the info in the "discharge" summary as well as anything else in the chart for that specific visit in determining my level of E/M

From your original question I was thinking that this was an inpatient admission, where discharge would clearly be on a different, later, date of service.

But it wouldn't hurt to education your physician about leaving $ on the table by not including such basic information as the patient's residence (or whatever could be part of social history)

F Tessa Bartels, CPC, CPC-E/M
 
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