tci E/M Coding Alert - 2018 Issue 7

Reader Question: Complete Your PFSH Understanding for Pertinent Documentation

Question: What are the two types of past medical, family, and social history (PFSH), and how do you distinguish between the two? South Carolina Subscriber Answer: There are two kinds of PFSH — pertinent and complete. With a pertinent PFSH, the provider reviews the history areas directly related to the problem identified in the HPI. For pertinent PFSH, the provider must document at least one item from any of the three history areas. “A pertinent PFSH usually only addresses information specific to the condition being treated during the encounter or that might have changed since the last time...

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