Question: Our doctors are great about documentation, except in one area. They rarely include any information in the past, family and social history (PFSH). This becomes a real problem when it’s the only thing standing between a lower code and a higher one. What’s the solution?
Answer: The only solution to this situation is communication. You must explain to your physicians in your ED that the PFSH is one of the determinants of a history level, which can ultimately impact the level of E/M service that you report. It’s very hard to calculate an accurate history level without knowing the PFSH. Many physicians say there isn’t time to record this information in the ED, but in reality, these details can be the lynchpin to determining a patient’s diagnosis, and since the doctor is asking about them, he must document them.
When you meet with the physicians who aren’t properly documenting the PFSH, bring along some sample documentation showing instances where an appropriately-completed PFSH might have increased the history level, and therefore the overall E/M level. Let them know the difference in reimbursement between the code you were forced to report and the one you could have reported so they understand the value of the PFSH in the future.