Part B Insider - 2017 Issue 4
PFSH 101: Hone Your PFSH Skills to Excel in History Coding
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Article Overview
This educational article explains the role of past, family, and social history in E/M documentation and why accurate history capture matters for service level assignment. It is aimed at coders, billers, auditors, and clinical staff who work with office and hospital documentation. The article covers the general history elements used in the Medicare E/M documentation framework, common categories of PFSH information, and broad guidance on when history is considered pertinent versus complete.
Why This Topic Matters
Accurate PFSH documentation affects how evaluation and management histories are supported in the record and helps reduce missed detail during coding review. Understanding these distinctions can support more consistent documentation assessment across patient encounter types.
Article Sections
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Correctly Identify PFSH Factors
Introduces the major history categories used in documentation and reviews the general kinds of information associated with each. The section also notes guidance from coding and Medicare-related sources.
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Distinguish Between the 2 Types of PFSH
Compares the two broad PFSH categories and discusses how they differ in scope. The section focuses on documentation completeness concepts in relation to E/M history review.
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Grasp This PFSH Analogy
Uses a simple analogy to explain the distinction between the history types and how documentation elements are counted. The section also relates the concept to general E/M subcategory requirements.
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How PFSH Relates to New Patients Vs. Established Patients
Discusses how PFSH expectations can differ between new and established patient encounters. The section includes general references to office visit categories and Medicare fee schedule context.
What You Will Learn
- The major components that make up PFSH in E/M documentation
- How pertinent and complete PFSH are distinguished at a high level
- How PFSH is discussed in relation to new and established patient encounters
- The general categories of information commonly captured in past, family, and social history
Who Should Read This
- Medical coders
- Billing staff
- Compliance staff
- Auditors
- Clinical documentation staff
- Practice administrators
Codes Discussed
Code Ranges Discussed
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