tci Part B Insider - 2013 Issue 1

Use These Tips to Determine the Level of PMFSH

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 medical, family and social history (PMFSH).  Therefore, the PMFSH helps determine patient history level, which has a great effect on the E/M level you can report. If you do not know the PMFSH level, you will be unable to decide which level of E/M code you should use on the claim. There are three levels of PMFSH: none, pertinent, and complete. Pertinent: To reach a detailed level of history for the encounter...

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