Outpatient Facility Coding Alert - 2013 Issue 4
Key Elements: Don't Let 1 Missing PMFSH Point Cost Your Practice $70 Per Encounter
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Article Overview
This article covers evaluation and management documentation focused on past medical, family, and social history (PMFSH) and how it influences visit leveling. It is aimed at coders, billers, and clinicians who document office and outpatient encounters, especially when history is reused from earlier visits or collected through forms. The discussion includes general Medicare documentation guidance, history element requirements, and the broader financial impact of missing or incomplete history documentation.
Why This Topic Matters
Incomplete history documentation can change the supported level of an evaluation and management service, affecting claim accuracy and reimbursement. The article helps readers understand why documenting, reviewing, and retaining prior history information matters for compliant coding and consistent payment.
Article Sections
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Determine the Level of PMFSH
Explains how PMFSH fits into the history component of evaluation and management services. It outlines the general levels of history and discusses documentation expectations referenced in Medicare guidance.
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Choose a Code Based on PMFSH Element Requirement
Describes how the documented history level relates to supported evaluation and management visit levels. It also addresses the impact of incomplete history documentation on office and outpatient encounter reporting and payment.
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Count Unchanged PMFSH in Current Encounter
Covers documentation of previously obtained history when it has not changed since an earlier visit. It discusses review, update, and source documentation practices for reused history information.
What You Will Learn
- How PMFSH affects the history component of evaluation and management documentation
- How documented history levels relate to visit level support
- How prior history can be reviewed and referenced in a current encounter
- Why complete history documentation can affect reimbursement
- How history forms and staff-collected information fit into the documentation process
Who Should Read This
- Medical coders
- Medical billers
- Physician practices
- Clinical documentation staff
- Providers documenting evaluation and management services
Codes Discussed
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