July 29th, 2016
When an Evaluation and Management service requires past medical, family and social history, (or one or two of those) here is what needs to be documented, and the rules around using one that is previously documented.
Past medical history includes the patient's chronic illnesses, previous illnesses, injuries and surgeries, medications and past treatment.
Social history includes smoking, drug, and alcohol use, employment, and living situation.
Family history includes a review of illness/health status of family members, including any that may be hereditary or genetic or place the patient at risk.
In order to count these three components of a history, document something from each one. How much is documented in each of the areas will be driven by medical necessity. For an office visit, the patient's medications and problem list alone will probably be sufficient for the physician to note. For an initial hospital service, the physician may find it necessary to document a more extensive past medical history. A patient who is young and healthy may have a short past medical history documented, while a patient being treated for recurrent cancer will have an extensive history documented, describing the course of the illness and past treatments for the disease.
This doesn't count: Social history: none. Everyone has social history. Many auditors and payers do not allow, "Family history non-contributory." CMS has not stated whether it considers that adequate, when admitting an elderly patient to the hospital. Some payers have specifically stated they do not cound "Family history non-contributory," while some are silent. The conservative advice is to always document something in family history.
The past medical, family and social history may be documented by a staff member or on a form completed by the patient, as long as there is evidence that the biling clinician reviewed those. For a new patient or consult, the clinician might say, "The past medical history shows that she has longstanding hyperllipidemia. She had successful carpal tunnel release in 2006. The remainder of the past medical, family and social history is documented on the health history form with today's date." This indicates that the physician has reviewed that form. Some physicians and NPPs also sign and date the form, making notations to supplement what is written. That is good, however, in the body of today's note, indicate that there is an additional form that is part of today's record and note that it was reviewed.
The guidelines do allow a clinician to use a history previously obtained for today's note, as long as the date and location of the previous note is mentioned, and the clinician indicates that the history was reviewed and their are no changes. "The remainder of the past medical, family and social history is unchanged from their previous admission of June 1, 2008. I reviewed this with the patient and there are no changes."
In an electronic medical record, the past medical, family and social history is brought forward from previous visits. This counts as long as the billing provider reviews this information with the patient, and indicates that. There may be a prompt that says, "Past medical history--reviewed and unchanged."