Reader Question: Determine PFSH for E/M Choice

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Note:  The following article synopsis was NOT provided by AAPC. It was created by Find-A-Code/innoviHealth.

Article Overview

This reader Q&A discusses how to assess personal past medical, family, and social history documentation when determining the overall history level for an evaluation and management office visit. It is aimed at coders and billers who need to evaluate new-patient documentation, understand where PFSH elements may appear in the note, and compare history completeness against the requirements for common office visit E/M selections.

Why This Topic Matters

Accurate history leveling can change which office or outpatient E/M service is appropriate, so understanding PFSH documentation helps support consistent code selection and compliant chart review.

What You Will Learn

  • How PFSH affects E/M history leveling
  • How to interpret documentation of history elements in a note
  • Where PFSH information may appear within clinical documentation
  • How PFSH completeness relates to new-patient office visit selection

Who Should Read This

  • Medical coders
  • Billing staff
  • Compliance staff
  • Physician documentation reviewers

Codes Discussed


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