tci E/M Coding Alert - 2017 Issue 4

PFSH 101: Hone Your PFSH Skills to Excel in History Coding

There are two kinds of PFSH — pertinent and complete. If you find it challenging to calculate the correct level of service for your evaluation and management (E/M) services, you are not alone. Medicare’s 1995 and 1997 E/M Documentation Guidelines recognize seven components to defining E/M levels, with the first three — history, examination, and medical decision making (HEM) — as the key components. The history component includes the following elements: chief complaint (CC); history of present illness (HPI); review of systems (ROS); and past medical, family, and social history (PFSH). The level of service will determine the...

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