tci E/M Coding Alert - 2017 Issue 1

You Be the Coder: Decode Social History For Newborns

Question: What would be considered an acceptable social history for a newborn? We are having some conflict with our documentation, and physicians are just saying things like "Family lives in Atlanta." Georgia Subscriber Answer: The social history of a patient, regardless of age, is one of the histories of Past, Family, and/or Social History (PFSH), which is then one of the three elements that define the history component of an E/M service. Both the 1995 and 1997 documentation guidelines for evaluation and management (E/M) services define social history as "an age appropriate review of past and current activities...

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