PFSH Documentation: Q and A

October 20th, 2017 - Shannon DeConda, CPC, CPC-I, CEMC, CEMA, CPMA, CRTT

Categories: Documentation Guidelines Emergency Medicine Evaluation & Management (E/M)

Included with a NAMAS membership is the ability for members to submit their auditing questions to our auditing team for input. Occasionally, we spotlight some questions we feel pertains to the majority of our membership as an educational tool. This week, we will spotlight a question received related to personal family social history (PFSH).

Question: When coding an E/M visit in the emergency department, would you count all PFSH listed even if they don't pertain to the indication as to why the patient arrived?

Example: If a patient comes in because they were a passenger in an auto accident and were injured (i.e. arm laceration), do we really need to count the family history? I cannot seem to find any documentation supporting this.

Answer: That is a great question! According to Documentation Guidelines, the only category that "requires" one of the PFSH areas to be applicable is the pertinent level which supports the detailed level of history. My humble opinion is that in most instances, family history would be the least impactful in the emergency department setting, but it could certainly have relevance. The statement addressing this in documentation Guidelines reads:

A pertinent PFSH is a review of the history area(s) directly related to the problem(s) identified in the HPI.

For the complete category of PFSH, there is no such requirement as indicated in the statement below:

A complete PFSH is of a review of two or all three of the PFSH history areas, depending on the category of the E/M service.

Often, as auditors, we are unclear of requirements for various services, are hit with really puzzling situations, or just need reassurance that we are interpreting things the same way others do. Because auditing is so subjective, it's nice to hear that someone "has your back" or can provide insight to a topic you may be struggling with. Because of this, NAMAS has provided two ways for you to feel more confident in your auditing:

1. NAMAS Forum

The NAMAS forum is a discussion board to encourage interaction among members. Within the forum, you can post your questions and in turn, answer other members' questions related to various auditing topics. If you haven't visited our forum, you can find many good resources there. Click here to visit the NAMAS forum.

2. Ask An Auditor

As previously mentioned, as a NAMAS member, you may pose your auditing questions directly to our team for their input. We will distribute your question to our auditing team, and provide their opinion(s) to your question. We attempt to answer all questions as quickly as possible, but due to schedules of our team members and the number of questions we receive, we do outline that questions will be answered within five business days.

If you are currently a NAMAS member, we invite you to participate in our online forum and utilize this tool to help obtain information regarding auditing and compliance topics. In addition, the Ask an Auditor feature is available for your use within the members only area of our website.

If you are not currently a member, we invite you to sample the value a NAMAS membership can provide with a 30 day free trial membership. During your free trial, among other benefits, you will receive access to 4 of our educational webinar sessions, and receive 4 AAPC CEUs. Additionally, you will have the opportunity to pose your questions to our team as well for their input. Click here to register for your free 30 day trial membership. There is no credit card required to receive your trial membership, and if you determine that a membership fits your needs you will have the opportunity to become a member of NAMAS.

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