PFSH

PFSH is supposed to stand for Past Medical, Family and Social History. 

Past Medical History (PMH: A review of past illnesses, operations or injuries, which may include:

1. Prior illnesses or injuries

2. Prior operations

3. Prior hospitalizations

4. Current medications

5. Allergies

6. Age appropriate immunization status

7. Age appropriate feeding/dietary status

Coding Tip: Notice that current medications and allergies are each
considered to be individual elements of Past Medical History

Family History (FH): A review of medical events in the patient’s family which may include information about:

1. The health status or cause of death of parents, siblings and children

2. Specific diseases related to problems identified in the Chief Compliant, HPI, or ROS

3. Diseases of family members which may be hereditary or place the patient at risk

Social History (SH): An age appropriate review of the patient’s past and current activities which may include significant information about:

1. Marital status and/or living arrangements

2. Current employment

3. Occupational history

4. Use of drugs, alcohol or tobacco

5. Level of education

6. Sexual history

7. Other relevant social factors

There are two levels of PFSH :

1. Pertinent PFSH: At least ONE specific item from ANY of the three components of PFSH must be documented.

2. Complete PFSH: A review of two or all three of the PFSH components are required depending on the category of E/M service

At least ONE item from TWO out of three PFSH components must be documented for a Complete PFSH for:

1)   Established Office Patient
2)   ER visits
3)   Subsequent Nursing Facility Care
4)   Established Patient Domiciliary Care
5)   Established Patient Home Care

At least ONE specific item from THREE of the three PFSH components must be documented for a Complete PFSH for:

1)   New Office Patient
2)   Hospital Observation Services
3)   Hospital H&P
4)   Consultations
5)   Comprehensive Nursing Facility Assessments
6)   New Patient Domiciliary Care
6)   New Patient Home Care

Coding Tip: Many physicians overlook the fact that some follow-up encounters DO require a review of the PFSH.  You should carefully review the history requirements for each encounter before selecting and billing any E/M code.  

Coding Tip : You DO NOT need to re-record a PFSH if there is an earlier version available on the chart.  It is acceptable to review the old PFSH and note any changes.  In order to use this shortcut, you must note the date and location of the previous PFSH and comment on any changes in the information since the original PFSH was recorded.  For example, if you are seeing an established patient in the office you can say: “Comprehensive PFSH which was performed during a previous encounter was re-examined and reviewed with the patient.  There is nothing new to add today.  For details, please refer to my previous note in this chart, dated 10/23/2012 .” 

Coding Tip : It is not necessary that the physician personally perform the PFSH.  It is acceptable to have your staff record and document the PFSH or to let the patient fill out a PFSH questionnaire.  However, the physician MUST state that he or she reviewed the information and comment on pertinent findings in the body of the note.  In addition the physician should initial the PFSH questionnaire and maintain the form in the chart as a permanent part of the medical record. 

Coding Tip : Remember, it only takes ONE element from EACH component of PFSH to qualify for a complete PFSH.  There is no need to overload the documentation with superfluous information which may not be clinically relevant. 

Coding Tip : The PFSH may be recorded separately or may be documented within the HPI.  

Coding Tip: The following categories of E/M service NEVER require ANY PFSH:

• Subsequent Hospital Care (i.e. hospital progress notes)

• Follow-up Inpatient Consultations

• Subsequent Nursing Facility Care