Medicare Compliance & Reimbursement - 2015 Issue 7
Reader Questions: Skipping PFSH Can Cost You
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Article Overview
This reader Q&A focuses on evaluation and management (E/M) history documentation for office and outpatient visits, with attention to how personal past medical, family, and social history is assessed alongside HPI and review of systems. It is relevant to coders, auditors, and clinicians who review documentation completeness for patient visits and want to understand what broad documentation elements matter when determining whether a note supports a higher or lower E/M level.
Why This Topic Matters
History completeness can change whether an encounter supports a higher-level E/M service, so reviewers need to know where to look in the record and what documentation categories are being discussed.
Article Sections
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Question
Introduces a coding question about E/M level selection for a patient visit and the documentation elements under review.
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Answer
Summarizes the need to review personal past medical, family, and social history when evaluating the encounter documentation.
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How it works
Outlines the general levels of personal past medical, family, and social history and how they are distinguished in encounter documentation.
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Best bet
Explains the importance of counting documented history elements before selecting the appropriate E/M service level.
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Pointer
Notes where relevant history information is commonly found within the medical record.
What You Will Learn
- How personal past medical, family, and social history is considered in E/M documentation review
- How history elements relate to office/outpatient visit level selection
- Where documentation reviewers may find relevant history information in a patient note
- How this topic applies to new and established patient encounters
Who Should Read This
- Medical coders
- Coding auditors
- Physicians
- Clinical documentation staff
- Billing staff
Codes Discussed
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