Medicare Compliance & Reimbursement - 2010 Issue 1
Readers Question: PFSH Puts Added Value on Some E/Ms
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Article Overview
A coding Q&A focused on emergency department evaluation and management history elements, with emphasis on how past, family, and social history documentation can influence the level of service selected. It also touches on diagnosis reporting using a legacy ICD-9-CM code and is aimed at coders reviewing provider documentation for E/M level support.
Why This Topic Matters
Accurate history documentation can change the level of E/M service reported, so understanding how PFSH contributes to the overall history helps coders evaluate whether the record supports the selected visit level.
Article Sections
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Question
The reader presents an emergency department encounter and asks how the documented history elements affect E/M level selection.
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Answer
The response discusses reviewing the documented history components, with emphasis on past, family, and social history in relation to emergency department E/M coding.
What You Will Learn
- How history components are reviewed in an emergency department E/M encounter
- Why past, family, and social history documentation matters for level selection
- How diagnosis coding may be referenced alongside E/M reporting in a coding question-and-answer format
- What documentation details a coder may need to verify within the note
Who Should Read This
- Medical coders
- Coding auditors
- Emergency department coding staff
- Compliance reviewers
Codes Discussed
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