Reader Question: Focus on PFSH for E/M Code Selection

Why This Topic Matters

Accurate E/M code selection depends on documenting the required history components, and incomplete PFSH can affect the reported service level. The article helps readers determine whether a note supports a higher-level new patient visit and where to look for the relevant history elements.

Article Sections

1. Question

   A reader asks about determining the E/M level for a new patient office visit based on documented history, exam findings, and medical decision-making. The question centers on whether the history component is sufficiently complete.

2. Answer

   The response explains that PFSH must be reviewed when assessing the history level for this type of E/M service. It summarizes the general categories of PFSH completeness and how that affects code selection.

3. How it works

   This section outlines the general framework for PFSH documentation levels and how they are recognized in patient notes. It also describes the relationship between the history components needed for a comprehensive E/M history.

4. Best bet

   The article discusses how the documented PFSH level influences which office visit code may be appropriate for the encounter. It emphasizes reviewing the note carefully to determine the documented history level.

5. Pointer

   The final note explains that relevant history information may appear in different parts of the record rather than in a dedicated section. It directs readers to consider documentation found within broader history sections of the encounter note.