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Pfsh - I just began auditing

  1. #1
    Default Pfsh - I just began auditing
    Medical Coding Books
    I just began auditing consults for a specialist and she is not documenting family history. Per our Medicare carriers' guidelines, all three must be documented for a consult. If there is no family history, should I code it for an office visit - new patient even though we have a request from the patient's PCP for this consult? Thank you.
    Debby

  2. #2
    Location
    Milwaukee WI
    Posts
    4,466
    Default CPT requirements
    Who is your Medicare carrier? If they want family hx on ALL consults this is a much higher standard than CPT.

    CPT does not require a family history for consults at the lower levels.
    99241 and 99242 have no pfsh requirement at all. 99243 requires at least one item of pfsh that is pertinent (could be social or past medical or family, but any one of them gets you the level).

    Only 99244 and 99245 required a complete PFSH.

    Could it be your physician is coding a too-high level of consult?

    If the office is using a patient questionaire that has this info on it, the physician should be tying her note to that questionaire and indicating she reviewed that info on the date of exam.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  3. #3
    Default PFSH - all three required for consultations.
    Thanks, Tessa for responding.
    Our Medicare Carrier is HighMark, but the guidelines are from CMS - both the 1995 and 1997 guidelines state that "at least one specific item from each of the 3 history areas must be documented for a complete PFSH for consultations."
    You said that CPT does not require a family history for consults at the lower levels. - Is that information in the CPT book? Can you tell me where I can get that info so I can show it to the doctor? I hope I am understanding this correctly.
    Thank you
    Debby

  4. #4
    Location
    Milwaukee WI
    Posts
    4,466
    Default Combination of CPT and 95 or 97 guidelines
    Actually it's a combination of CPT and the 1995 or 1997 guidelines. (For the PFSH section there is no difference from 1995 to 1997.)

    CPT tells us that for 99241 you need a problem focused history. The guidelines tell us that for a PF history you do not need any PFSH

    CPT tells us that for 99242 you need an expanded problem focused history. The guidelines tell us that for a EPF history you do not need any PFSH

    CPT tells us that for 99243 you need a detailed history. The guidelines tell us that for a detailed history you need a pertinent PFSH (any one of them has to be documented)

    CPT tells us that for 99244 and 99245 you need a comprehensive history. The guidelines tell us that for a comprehensive history you need to complete all three areas of the PFSH.

    The same guidelines apply to inpatient consults 99251-99255.

    So, yes you need all three for a complete PFSH, but you only need a complete PFSH for levels 4 and 5. All the audit tools I've ever seen have this information on them.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

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