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Pfsh - Question for everyone

  1. #1
    Default Pfsh - Question for everyone
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    Question for everyone.

    New patients that do not have a family history listed, are we able to count a PFSH for this patient? We have one physician who will list past history and social history, but not family history.
    We are having a discussion that include:
    It's not necessary to have all 3 history areas and still get a pertinent PFSH or is it necessary to have all 3 history areas and cannot charge a visit if all aren't there.

    Also, this same physician has the patient fill out a history sheet, but does not refer to it in his office notes at all. Can we count the history sheet? I'm saying not, because he doesn't refer to it and it's not signed by him.

    Thoughts anyone? Please?

  2. #2
    Default
    You only need all 3 to get a comprehensive history, so it is not a problem unless they are wanting to bill level 4 or 5.

    If he doesn't reference the history sheet, I wouldn't count it either.

    My thoughts,

    Laura, CPC

  3. #3
    Default pfsh
    Yes, he was charging 99204, and then eliminating the history altogether or just the family history. Thanks for your response. Then we can drop the visit to either a 99202 or whatever that conforms to the documentation he does have?

    I appreciate your help.
    Anna

  4. #4
    Location
    Milwaukee WI
    Posts
    4,466
    Default 99203
    Coding 99203 requires a detailed history, detailed exam and Low MDM.

    As far as PMFSH is concerned, you need to cover at least one of these areas. So if your doctor is documenting past medical history or social history that might be enough (depending on HPI and ROS) to qualify for a Detailed History.

    You can count a patient questionaire only if it is specifically referenced by date, for example: I have reviewed the PMFSH and ROS as per the patient-completed health questionaire completed mm/dd/yy. The provider should also sign/date the patient questionaire.

    F Tessa Bartels, CPC, CEMC

  5. #5
    Default Pfsh
    Quote Originally Posted by FTessaBartels View Post
    Coding 99203 requires a detailed history, detailed exam and Low MDM.

    As far as PMFSH is concerned, you need to cover at least one of these areas. So if your doctor is documenting past medical history or social history that might be enough (depending on HPI and ROS) to qualify for a Detailed History.

    You can count a patient questionaire only if it is specifically referenced by date, for example: I have reviewed the PMFSH and ROS as per the patient-completed health questionaire completed mm/dd/yy. The provider should also sign/date the patient questionaire.

    F Tessa Bartels, CPC, CEMC
    Thanks, I appreciate your response. It helps tremendously.

  6. #6
    Location
    Greeley, Colorado
    Posts
    2,045
    Default
    I believe for a new patient you must document 2 of 3 from PFSH for a detailed history.
    Lisa Bledsoe, CPC, CPMA

  7. #7
    Default
    Hi - per my audit tool you need "one or two" for a detailed history (for New/ Initial visits) and all three for a comprehensive hx. Of course, HPI and ROS must be documented accordingly as well.

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