Part B Coding Coach: Stop Forfeiting Level Four and Five E/Ms With 3 PMFSH Tips

Why This Topic Matters

Accurate history documentation can affect whether an encounter supports higher-level evaluation and management reporting. The article is useful for coders, billers, and clinical staff who need to recognize when history elements are present, reused, or reviewed in accordance with documentation standards.

Article Sections

1. Determine the Level of PMFSH

   Introduces the history component of evaluation and management services and explains the role of past medical, family, and social history in determining history level. It also summarizes the broad categories of PMFSH recognized in the article.

2. Choose a Code Based on PMFSH Element Requirement

   Discusses how the documented history level relates to E/M code selection and compares general code levels for new and established patient services. It also notes that other key components may affect established patient reporting.

3. Count Unchanged PMFSH in Current Encounter

   Covers documentation of previously recorded history information when it has not changed and the need to show review of earlier information. It also addresses who may complete the history form and the importance of physician review.