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Last Modified: 2/10/2018 Location: FL, PR, USVI Business: Part A, Part B

Interval history FAQ

Q: If the Current Procedural Terminology® (CPT®) manual requires only an “interval history” for a particular category of patient visit, do I need to make any selections in the PFSH section of the E/M interactive worksheet?
A: Yes, to accurately reflect the services performed and documented in the patient’s record, you should indicate any areas of past, family, and/or social history (PFSH) reviewed by the physician.
Note: The E/M interactive worksheet bases its calculations on the requirements specified in the E/M Documentation Guidelines for Evaluation and Management Services (1995 and/or 1997) and the selections made by the user.

Performance and documentation requirements for key E/M components

There are three key components for which performance and documentation requirements help determine the level of evaluation and management (E/M) services furnished by the provider: History, Examination, and Medical Decision Making.
For some categories of visits (e.g., initial hospital care, initial nursing care) the criteria for all three components must be met to bill for a specific level of E/M code. However for certain categories of patient visits, (e.g., subsequent hospital care, subsequent nursing facility care) only two out of the three major components are required.
Therefore, for those categories of visits requiring only two out of three components, if the criteria for the Examination and Medical Decision Making components are met for a particular level of E/M code, meeting the criteria for History is not required. However, if the criteria for either the Examination or Medical Decision Making components are not met for a particular level of E/M code, the requirements for History must be met.

Interval history and PFSH – when history is required

Although the E/M guidelines state that for a category of patient visit requiring only an “interval history” (e.g., subsequent hospital care, subsequent nursing facility care) the physician does not have to record PFSH information, the guidelines also specify that a review of PFSH is required to achieve a Pertinent PFSH or a Complete PFSH.
However, the nature of the PFSH review for these types of visits (e.g., subsequent hospital care, subsequent nursing facility care) may vary from a PFSH review for a category of visit requiring a more in-depth history of the patient (e.g., initial hospital care).
Example: While making his rounds, a physician visits a patient who was admitted to the nursing facility three weeks ago. The patient was recently diagnosed with pneumonia and is experiencing shortness of breath as well as wheezing.
Before prescribing a Lasix® injection, the physician reviews the PFSH information contained within the patient’s medical record. While reviewing the patient’s past medical history, he discovers that although the patient is allergic to most sulfa medications, she has taken the oral form of Lasix® (prescribed as a diuretic) with great success and has experienced no adverse reaction. If the physician did not review any other facet of PFSH (e.g., social or family history), then the level of PFSH=Pertinent.
In addition, both sets of E/M documentation guidelines specify that to qualify for a particular level of total history, the levels for all three elements of history (i.e., HPI, ROS, and PFSH) must be determined:

History of present illness (HPI)
Review of systems (ROS)`
Past, family, and/or social history (PFSH)
Total history level
Brief
N/A
N/A
Problem Focused
Brief
Problem Pertinent
N/A
Expanded Problem Focused
Extended
Extended
Pertinent
Detailed
Extended
Complete
Complete
Comprehensive
The 1995 and 1997 E/M documentation guidelines specify the following review requirements for Pertinent and Complete PFSH levels:
Pertinent PFSH: A review of at least one PFSH history area directly related to the problem(s) identified in the HPI
Complete PFSH: A review of two or all three PFSH history areas, depending on the category of E/M service
Note: A review of two of the three PFSH history areas is sufficient for subsequent hospital care and subsequent nursing facility care patient visits

How to document a physician’s review of PFSH

The E/M documentation guidelines also furnish the following recommendations for documenting the physician’s review of PFSH and/or ROS:
The chief complaint (CC), ROS, and PFSH may be listed as separate elements of history, or they may be included in the description of the history of the present illness.
An ROS and/or a PFSH obtained during an earlier encounter does not need to be re-recorded if there is evidence that the physician reviewed and updated the previous information. This may occur when a physician updates his or her own record or when several physicians in an institutional setting or group practice use a common record. The physician’s review and update may be documented by:
Describing any new ROS and/or PFSH information or notating there has been no change to the information
Notating the date and location of the earlier ROS and/or PFSH
To document that the physician reviewed the ROS and/or PFSH recorded by others (e.g., ancillary staff, a form completed by a patient), there must be a notation supplementing or confirming the information recorded by the other individuals.

Other resources

According to Chapter 12, Section 30.6.1 -- Selection of Level of Evaluation and Management Service of the Medicare Claims Processing Manual:
A/B MACs (B) must advise physicians that to bill the highest levels of visit codes, the services furnished must meet the definition of the code (e.g., to bill a Level 5 new patient visit, the history must meet CPT’s definition of a comprehensive history).
The comprehensive history must include a review of all the systems and a complete past (medical and surgical) family and social history obtained at that visit. In the case of an established patient, it is acceptable for a physician to review the existing record and update it to reflect only changes in the patient’s medical, family, and social history from the last encounter, but the physician must review the entire history for it to be considered a comprehensive history.
Sources: 1995 Documentation Guidelines for Evaluation & Management Services
1997 Documentation Guidelines for Evaluation and Management Services
Medicare Claims Processing Manual, Chapter 12 - Physicians/Nonphysician Practitioners
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