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Getting history information

  1. #1
    Question Getting history information
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    When reviewing a patients family and social history and there is no qualifying or pertinent information related to the HPI or chief complaint, but it is documented by the provider that they were discussed, if all other areas of comprehensive history are discussed, will those qualify the PFSH as complete, allowing for a comprehensive history?

  2. #2
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    Quote Originally Posted by MWoessner View Post
    When reviewing a patients family and social history and there is no qualifying or pertinent information related to the HPI or chief complaint, but it is documented by the provider that they were discussed, if all other areas of comprehensive history are discussed, will those qualify the PFSH as complete, allowing for a comprehensive history?
    I'm not sure I completely understand the question, but as I read this, I think you are asking whether, if the provider has documented all of the required elements of PFSH, you can count them toward the PFSH level if they are not 'qualifying or pertinent information related to the HPI or chief complaint' - or conversely, if the elements are not related, then should they be 'disqualified' and not counted.

    If I'm correct in my interpretation of the question, then I would answer that yes, the PFSH should be counted if the provider has documented them and discussed them. As there are no coding guidelines for how to make a determination as to whether or not an element of PFSH 'qualifies' or is 'pertinent', I'm not sure how a coder would do that appropriately without clinical guidance. Providers do not always explain in their notes why they have to ask the patients about certain things in history or why they need to record certain observations, and there may be valid clinical reasons for gathering that information that are not immediately apparent to a coder. Unless you have the clinical training to make that determination, or your practice has given you some kind of guidelines on how and when to identify unnecessary elements of documentation that should be disqualified, then I recommend adhering to the standard coding guidelines and evaluating the E/M levels accordingly. Hope that helps some.
    Thomas Field, CPC, CEMC

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