Outpatient Facility Coding Alert - 2018 Issue 2
Reader Question: Use This Bucket List to Decide Between Different PFSH
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Article Overview
This reader Q&A discusses how past, family, and social history documentation is classified in evaluation and management settings. It is aimed at coders and clinical documentation staff who need a high-level understanding of when different history levels are expected across E/M subcategories. The article provides a conceptual explanation of the topic and broad guidance about where this documentation may or may not be required, without focusing on specific diagnosis or procedure coding.
Why This Topic Matters
Accurate history documentation is a core part of E/M code selection and compliance review. Understanding the distinction between history types helps coding and documentation teams assess whether charting supports the level of service being reported.
What You Will Learn
- The difference between pertinent and complete past, family, and social history documentation
- How PFSH relates to evaluation and management history requirements
- Which broad E/M subcategories may call for different levels of history documentation
- Why some care settings may not require PFSH documentation at all
Who Should Read This
- Medical coders
- Coding auditors
- Clinical documentation improvement staff
- Physicians and advanced practice providers
- Billing and compliance professionals
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