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smaher82

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When it comes to a new pt office 99203 visit can you please tell what is required for pfsh . I am reading conflicting things. Is it 2 elements from from any of the 3 or is it 1 element from all 3?
 
jmcpolin said:
for a 99203 it is 1 from the 3 for 99204 it is 2 or 3 from the 3, does that make sense?
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According to all my auditing tools/cms/95-97 guidelines for a level 99203 2 pertinent histories are needed from either personal, family, or social. for a level 99204 and 99205 all 3 have to be documented. It is only for an established patient level 99215 that 2 pertient histories are needed.

95/97 guidelines:
A complete PFSH is of a review of two or all three of the PFSH history areas, depending on the
category of the E/M service. A review of all three history areas is required for services that by
their nature include a comprehensive assessment or reassessment of the patient. A review of two
of the three history areas is sufficient for other services.
!DG At least one specific item from two of the three history areas must be
documented for a complete PFSH for the following categories of E/M
services: office or other outpatient services, established patient; emergency
department; subsequent nursing facility care; domiciliary care, established
patient; and home care, established patient.
!DG: At least one specific item from each of the three history areas must be
documented for a complete PFSH for the following categories of E/M
services: office or other outpatient services, new patient; hospital
observation services; hospital inpatient services, initial care; consultations;
comprehensive nursing facility assessments; domiciliary care, new patient;
and home care, new patient.

Below is a great audit tool. I am in Florida, but this can give you a bit more help with documentation.

http://medicare.fcso.com/EM/165590.asp

Hope this Helps,

Ivonne CPC, CPMA
 
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