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

Why This Topic Matters

Understanding how history documentation is captured and credited can affect whether an encounter supports higher-level E/M reporting. The article is relevant for teams that want to align documentation review with payer expectations and avoid losing credit for history elements.

Article Sections

1. Determine the Level of PMFSH

   Introduces the history component of E/M services and outlines the broad levels of past, family, and social history used in documentation review. It also notes how those levels relate to the history portion of an encounter.

2. Choose a Code Based on PMFSH Element Requirement

   Discusses how the documented history level relates to E/M code selection in general terms. It includes broader commentary on how history interacts with the other major E/M components for established patient services.

3. Count Unchanged PMFSH in Current Encounter

   Covers how previously recorded history may be handled when it has not changed and what documentation support is needed in the current record. It also addresses completion of history forms by the patient or nurse and physician review of that information.