Medicare Compliance & Reimbursement - 2013 Issue 1
Use These Tips to Determine the Level of PMFSH
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Article Overview
This article covers the role of past medical, family, and social history in evaluation and management documentation. It explains the general PMFSH levels, how that history element affects E/M history level selection, and how prior history information may be carried forward when it has not changed. The article is relevant for coders, billers, and clinicians working with E/M documentation standards.
Why This Topic Matters
PMFSH documentation can affect the reported history level and therefore influence evaluation and management coding selection. Understanding the documentation expectations helps reduce incomplete records and supports accurate claim reporting.
Article Sections
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PMFSH and E/M history level
Introduces the PMFSH component within E/M history and explains its relationship to overall history level. Summarizes the broad PMFSH levels discussed in the article.
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Choose a code based on PMFSH element requirement
Describes how documentation level for this history element relates to E/M code selection. Includes general examples of how history level may affect new and established patient services.
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Count unchanged PMFSH in current encounter
Discusses how previously documented history may be handled when it has not changed. Covers the need to indicate review of prior information and to reference the earlier documentation source.
What You Will Learn
- How PMFSH fits into the history component of E/M documentation
- The broad PMFSH levels discussed in the article
- How unchanged prior history can be handled in a later encounter
- Why review and update of earlier documentation matters
Who Should Read This
- Medical coders
- Billing staff
- Physicians and other clinicians
- E/M documentation reviewers
Codes Discussed
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