decisionhealth Newsletters, Answer Books - 2009 Issue 2 (February)
Appendix C - 1995 EM Guidelines / Past family and social history (PFSH)
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Article Overview
This reference article covers the past, family, and social history element used in 1995 evaluation and management documentation guidelines. It is relevant to coders, auditors, clinicians, and compliance staff who need a clear understanding of how PFSH is categorized across common E/M service types and which service categories call for different levels of documentation.
Why This Topic Matters
PFSH documentation is a core part of E/M history requirements, and the amount of history needed varies by service setting and patient status. Knowing the guideline structure helps support more accurate record review and documentation compliance.
What You Will Learn
- What the PFSH component includes
- How PFSH is classified within E/M history documentation
- Which service categories reference interval history versus PFSH
- How documentation expectations differ across office, hospital, nursing facility, domiciliary, home care, emergency department, and consultation settings
Who Should Read This
- Medical coders
- Clinical documentation specialists
- Auditors
- Physicians and advanced practice providers
- Compliance professionals
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