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Documenting PFSH in a Medical Record

  1. #1
    Default Documenting PFSH in a Medical Record
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    If my providers are stating

    Completed a review of patient's allergies, current medications, active and chronic problems, surgeries and hospitalizations, family history, social/work history. (their name, date and time)

    Would this statement count as it being completed? This is the way our EMR is set up and we are constantly being down-coded for history. CC, HPI and ROS all seem to follow the level being billed.

    I'm not sure I agree with this statement but have physicians pushing back and would like feedback from someone other than myself.

    Our clinics are strictly for work comp visits.
    Thank you for any help.

  2. #2
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    In my experience with E/M coding and Workers Compensation (WC) companies, WC often play by their own rules when you are treading in gray waters.
    The CMS E/M guidelines are not clear cut when it comes to overarching statements for the History components you've mentioned, however in our practice we work hard on being more proactive than what the CMS guidelines say. This has often proved useful in defending our level of services when delineating the Past Medical, Family and Social Histories by itemizing them, with specific information to that visit.

    For example, patient A comes in for complaint of elevated blood pressure, fills out a standard Health Questionnaire and gives it to the nurse. Nurse hands that to the provider and the doc briefly goes over the form with the patient. Documentation reflects that the patient has a Past Medical History of surgery (dated) Family History of HTN, and a pertinent Social History (Married). While some coders might argue you could (and sometimes you might get away with getting paid) just use a blanket statement, auditors tend to favor more specificity. WCs add another layer to this complexity, as they do not always follow CMS guidelines, but stick more religiously to their own instead.

    Unfortunately, I don't have good links or references for you to provide to your providers, however I would start with reaching out to the bigger WC companies and ask for their policies. Dig a little deeper than the front line Customer Reps if you can, if you are getting nowhere.

    Personally as an auditor I would tend to agree with the WCs in this example, and not accept mere blanket statements (not a big fan of those), as they often do not convey specificity of the patient visit and current concerns.

    Hope this guides you somewhat, I know it's not a complete answer to what you're looking for, but perhaps a pointer.
    "When you have exhausted all possibilities, remember this: You haven't!"
    -Thomas Edison

  3. #3
    Default Documenting PFSH in a Medical Record
    Thank you. I do appreciate your help and advice. WC carriers are very hard to get your questions answered. This has been helpful to me.

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