Ophthalmology Coding Alert: Avoid Losing Level Four and Five E/Ms with These PFSH Tips

If the patient or a nurse documents the history, the job of your ophthalmologist's gets easier

You might be losing up to $69 per E/M, if your ophthalmologist glosses over a patient's past family and social history (PFSH).

As the top-level E/M codes need PFSH elements, accurately counting the number of PFSH items could result in more money.

For coding purposes, the history portion of an E/M service requires all three elements –

history of present illness (HPI),

review of systems (ROS),

and past family and social history (PFSH).

Thus, the PFSH helps define patient history level, which influences the E/M level you can report. Though, medical necessity for performing a comprehensive history must be marked in the patient progress notes. It may well be a standard of care to get a comprehensive history with new patients or patients who have not been seen for a year or more, but it is clear that a comprehensive history is not essential if the patient is being seen only days or weeks apart.
Altogether, there are following three levels of PFSH:

N/A

pertinent,

complete

Pertinent: You need an appropriate PFSH to reach a comprehensive level of history for the encounter. You need at least one specific item from any of the above listed three PFSH areas to attain the pertinent level. When the physician inquires only about one history area related to the main problem, this is a pertinent PFSH.
Complete: A complete PFSH includes at least one particular item from two of the three areas for the following E/M services' categories:

Established patient office/outpatient services

Emergency department services

Established patient domiciliary care

Established patient home care.

Remember that is not necessary to perform the PFSH for subsequent hospital visits or subsequent nursing facility care.
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