Medicare Compliance & Reimbursement - 2019 Issue 2
E/M Coding: Quell E/M History Quandaries with PFSH Basics
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Article Overview
This premium article is for coders, auditors, and billing professionals who need a clearer understanding of how past medical, family, and social history supports evaluation and management documentation. It summarizes the core PFSH components, distinguishes the general categories of history used in coding guidance, and explains why documentation completeness matters for E/M service support.
Why This Topic Matters
Accurate PFSH documentation is a common source of E/M coding uncertainty, and gaps or ambiguity in the record can affect whether the documented history supports the selected visit level. The article helps readers understand the scope of documentation expectations so they can assess E/M notes more confidently.
Article Sections
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Tip 1: Know What Information is Needed
Introduces the three PFSH history areas and summarizes the types of information associated with each area in coding guidance.
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Tip 2: Know the Difference Between Pertinent and Complete
Explains the general distinction between the two history types and notes that Medicare guidance is used to apply the definitions in E/M documentation.
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Tip 3: Know Why This Is Important
Describes why the extent of PFSH documentation matters for E/M history support and visit-level selection.
What You Will Learn
- How PFSH fits into E/M documentation review
- The broad categories that make up past, family, and social history
- How coding guidance distinguishes pertinent and complete history
- Why documentation completeness can affect E/M support
Who Should Read This
- Medical coders
- Coding auditors
- Billing staff
- Physician practice staff
- Compliance professionals
Codes Discussed
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