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Effective January 1, 2023, this information is no longer up-to-date. The material on this page covers only the 1995 and 1997 E/M guidelines and is no longer accurate. A new set of E/M guidelines was released in 2021, with some minor modifcations added for 2023. These new guidelines are now used to document all encounters in both the outpatient and inpatient settings. For the most recent E/M coding guidance, visit our home page here.
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Aside from pointing out the mysterious absence of the "M" from its acronym, there is nothing very interesting to say about the PFSH. PFSH; is supposed to stand for Past Medical, Family and Social History. Nobody knows why they dropped the 'M".
Past Medical History (PMHA review of past illnesses, operations or injuries, which may include:
- Prior illnesses or injuries
- Prior operations
- Prior hospitalizations
- Current medications
- Allergies
- Age appropriate immunization status
- Age appropriate feeding/dietary status
E/M University 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:
- The health status or cause of death of parents, siblings and children
- Specific diseases related to problems identified in the Chief Compliant, HPI, or ROS
- 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:
- Marital status and/or living arrangements
- Current employment
- Occupational history
- Use of drugs, alcohol or tobacco
- Level of education
- Sexual history
- Other relevant social factors
There are two levels of PFSH :
- Pertinent PFSH: At least ONE specific item from ANY of the three components of PFSH must be documented.
- 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 components of PFSH 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
E/M University CodingTip: 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.
E/M University 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 11/23/2004.”
E/M University 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.
E/M University 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.
E/M University Coding Tip : The PFSH may be recorded separately or may be. documented within the HPI.
E/M University 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
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