General Surgery Coding Alert - 2018 Issue 7
Reader Question: Complete Your PFSH Understanding for Pertinent Documentation
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Article Overview
This article is a coding-education Q&A about past medical, family, and social history documentation in evaluation and management (E/M) services. It is aimed at coders, billers, auditors, and clinical documentation staff who need a general understanding of how history documentation is categorized and when broader history review is expected. The discussion references the 1995 and 1997 E/M Documentation Guidelines and focuses on the scope of history documentation rather than on any specific procedure or diagnosis coding.
Why This Topic Matters
Understanding PFSH documentation is important for E/M chart review, documentation support, and audit readiness. The article helps readers distinguish between documentation scopes that affect how history is captured in clinical records.
Article Sections
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Question
Introduces the documentation topic and asks how the two types of PFSH are distinguished.
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Answer
Summarizes the two broad PFSH categories and frames the rest of the discussion around history documentation scope.
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Pertinent PFSH
Describes the narrower history review approach and the general area of focus for this type of documentation.
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Complete PFSH
Explains the broader history review approach and relates it to E/M service categories and guideline-based documentation expectations.
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When complete PFSH is expected
Provides general situations where broader history documentation may be encountered in clinical practice and record review.
What You Will Learn
- The general distinction between pertinent and complete PFSH
- How PFSH fits into E/M documentation
- Why history documentation scope matters for chart review
- Which guideline sources are referenced for E/M history documentation
Who Should Read This
- Medical coders
- Medical billers
- Clinical documentation staff
- Compliance auditors
- Revenue cycle staff
- Physician practices
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