E & M coding - Past, Family, and/or Social History (PFSH)

 PFSH consists of a review of three areas:

** Past history including experiences with illnesses, operations, injuries, and treatments;

** Family history including a review of medical events, diseases, and hereditary conditions that may place the patient at risk; and

** Social history including an age appropriate review of past and current activities.


The two types of PFSH are: pertinent and complete.

A pertinent PFSH is a review of the history areas directly related to the problem(s) identified in the HPI. The pertinent PFSH must document at least one item from any of the three history areas.

In the following example, the patient’s past surgical history is reviewed as it relates to the identified HPI:

** HPI: Coronary artery disease.

** PFSH: Patient returns to office for follow up of coronary artery bypass graft in 1992. Recent cardiac catheterization demonstrates 50 percent occlusion of vein graft to obtuse marginal artery.

A complete PFSH is a review of two or all three of the areas, depending on the category of E/M service. A complete PFSH requires a review of all three history areas for services that, by their nature, include a comprehensive assessment or reassessment of the patient. A review of two history areas is sufficient for other services.

At least one specific item from two of the three history areas must be documented for a complete PFSH for the following categories of E/M services:

** Office or other outpatient services, established patient;

** ED;

** Domiciliary care, established patient;

** Subsequent NF care (if following the 1995 documentation guidelines); and

** Home care, established patient.

At least one specific item from each of the history areas must be documented for the following categories of E/M services:

** Office or other outpatient services, new patient;

** Hospital observation services;

** Hospital inpatient services, initial care;

** Comprehensive NF assessments;

** Domiciliary care, new patient; and

** Home care, new patient.


In the following example, the patient’s genetic history is reviewed as it relates to the current HPI:

** HPI: Coronary artery disease.

** PFSH: Family history reveals the following:

• Maternal grandparents – Both + for coronary artery disease; grandfather: deceased at age 69; grandmother: still living.

• Paternal grandparents – Grandmother: + diabetes, hypertension; grandfather: + heart attack at age 55.

• Parents – Mother: + obesity, diabetes; father: + heart attack at age 51, deceased at age 57 of heart attack.

• Siblings – Sister: + diabetes, obesity, hypertension, age 39; brother: + heart attack at age 45, living.