Laureen shows you her proprietary “Bubbling and Highlighting Technique”
Download your Free copy of my "Medical Coding From Home Ebook" at the top right corner of this page 2018 CPC Practice Exam Answer Key 150 Questions With Full Rationale (HCPCS, ICD-9-CM, ICD-10, CPT Codes) Click here for more sample CPC practice exam questions with Full Rationale Answers Click here for more sample CPC practice exam questions and answers with full rationaleTag Archives: PFSH
Past, Family, and/or Social History (PFSH)
Per E/M guidelines: You do not need to re-record a ROS and/or a PFSH obtained during an earlier encounter if there is evidence that the physician reviewed and updated the previous information. This may occur when a physician updates his or her own record or in an institutional setting or group practice where many physicians use a common record.
You may document the review and update by:
Describing any new ROS and/or PFSH information or noting there is no change
in the information
Noting the date and location of the earlier ROS and/or PFSH
by him signing and dating below, is this sufficient to account for a PFSH????
This is an example of the providers documentation:
Chief Complaint
Patient presents with
Hypertension
*
*
HPI patient is here for htn,. He has been on medication in the past. But has not had insurance. Now he was unable to past a dot physical to drive big rig.
*
Review of Systems
Neurological: Positive for headaches.
*
*
*
Patient’s medications, allergies, past medical, surgical, social and family histories were reviewed and updated as appropriate.
*
*
Objective:
Physical Exam
Constitutional: He is oriented to person, place, and time. He appears well-developed and well-nourished.
Cardiovascular: Normal rate.
Neurological: He is alert and oriented to person, place, and time.
*
*
*
Assessment:
*
1. HTN, goal below 140/90 losartan (COZAAR) 50 MG tablet
* DISCONTINUED: losartan (COZAAR) 50 MG tablet
*
RTc in 1 week for bp control.
Electronically signed by XXXXX, DO at 10/23/2017 *9:40 AM
Satisfying PFSH
E&m pfsh
A Provider will list a Past History in detail, a Social History in detail, but will state Family History is "None".
Is this acceptable to consider PFSH is complete ?
Thanks,
Kavita Parab
Opinion on PFSH
If a provider documents in a patient’s record, I have reviewed and confirmed Family History, Medical History, and Social History with the patient and listed it above and below unless there was no contributory information.
Would you except this as elements for the PFSH and give the doctor credit?
Thank You
E/M Coding Lever for New Patient with PFSH = NONE
Any information and where to find it would be appreciated. Thank you.
Claudia