PAST, FAMILY, AND/OR SOCIAL HISTORY (PFSH)

The PFSH consists of a review of three areas:

• past history (the patient's past experiences with illnesses, operations, injuries and treatments); 
• family history (a review of medical events in the patient's family, including diseases which may be hereditary or place the patient at risk); and 
• social history (an age appropriate review of past and current activities).

For the categories of subsequent hospital care, follow-up inpatient consultations and subsequent nursing facility care, CPT requires only an "interval" history. It is not necessary to record information about the PFSH.

A pertinent PFSH is a review of the history area(s) directly related to the problem(s) identified in the HPI.

DG: At least one specific item from any of the three history areas must be documented for a pertinent PFSH.

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

DOCUMENTATION OF EXAMINATION

The levels of E/M services are based on four types of examination that are defined as follows:

Problem Focused -- a limited examination of the affected body area or organ system. 

Expanded Problem Focused -- a limited examination of the affected body area or organ system and other symptomatic or related organ system(s). 

Detailed -- an extended examination of the affected body area(s) and other symptomatic or related organ system(s). 

Comprehensive -- a general multi-system examination or complete examination of a single organ system.  

For purposes of examination, the following body areas are recognized: 

• Head, including the face 
• Neck 
• Chest, including breasts and axillae 
• Abdomen
• Genitalia, groin, buttocks 
• Back, including spine 
• Each extremity 

For purposes of examination, the following organ systems are recognized: 

• Constitutional (e.g., vital signs, general appearance) 
• Eyes 
• Ears, nose, mouth, and throat 
• Cardiovascular 
• Respiratory 
• Gastrointestinal 
• Genitourinary 
• Musculoskeletal 
• Skin 
• Neurologic 
• Psychiatric 
• Hematologic/lymphatic/immunologic 

The extent of examinations performed and documented is dependent upon clinical judgment and the nature of the presenting problem(s). They range from limited examinations of single body areas to general multi-system or complete single organ system examinations.

DG: Specific abnormal and relevant negative findings of the examination of the affected or symptomatic body area(s) or organ system(s) should be documented. A notation of "abnormal” without elaboration is insufficient. 

DG: Abnormal or unexpected findings of the examination of the unaffected or asymptomatic body area(s) or organ system(s) should be described. 

DG: A brief statement or notation indicating "negative" or "normal" is sufficient to document normal findings related to unaffected area(s) or asymptomatic organ system(s). 

DG: The medical record for a general multi-system examination should include findings about 8 or more of the 12 organ systems.