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Social History - greatly appreciated

  1. #1
    Smile Social History - greatly appreciated
    Medical Coding Books
    I have a patient that was seen in the ED and in the HPI the Dr states "caregiver states blah blah blah,,, My question is would you consider that the pt's caregiver is enough to be considered for the Social History

    All replies would be greatly appreciated.

  2. Default
    I say yes, but would venture that the physician would need to be careful in who he shared personal information with about the patient.

  3. #3
    Default
    i would credit it for "decision to obtain history from someone other than the patient" for amount of data to be reviewed for the MDM.

  4. #4
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    I agree with your statement jbagsic.

    Roxanne Thames, CPC



    Quote Originally Posted by jbagsic View Post
    i would credit it for "decision to obtain history from someone other than the patient" for amount of data to be reviewed for the MDM.

  5. #5
    Default
    You only need to state who the information was obtained from and why the information was not available from the patient, ie "S/H info obtained from caregiver as patient is demented."
    Marc A. Kaplan, D.O., CPC

  6. #6
    Default
    Did the patient give the other elements of the PFSH? Why couldn't the patient give the social history? Was there something the patient was not telling the physician? Did the physician ask for the caregiver's info? I wouldn't credit it to the "decision to obtain history from someone other than the patient" in the MDM so quickly. If the patient was demented or intubated or in a coma then you would be able to get credit for PFSH as long as physician documented that s/he was unable to obtain history because pt .... or obtained PFSH from caregiver because pt....
    Christina Lee Wagner, CPC, CPC-H

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