Hey, Where’s the PFSH?
During our pre-bill audits, we have found a common phase documented- Past, Family, Social History “noncontributory.” While this seems appropriate to clinicians, it’s a big no-no to auditors.
Many providers have asked, “Is it acceptable to use the phrase ‘noncontributory’ to describe past family or social history?
Unfortunately, neither CMS nor any of the regional Medicare Administrative Contractors (MAC) have stated that they will accept those phrases. In fact, National Government Services (NGS) flatly state that they will not give credit for a family history that is documented as “noncontributory.” This phrase does not indicate what was addressed. Did the nurse or physician ask specific questions (any family history of heart disease?)
From NGS E&M FAQs:
- For the family history, will NGS accept “noncontributory?”
- Answer: The family history includes the age of parents and siblings (if alive) and their current health status, or their age and cause of death if they are deceased. Documentation should also reference diseases related to problems identified in the Chief Complaint and/or Review of Systems. In addition, documentation should describe potentially hereditary conditions that may place the patient at risk.
- CMS has provided the following clinical example in CMS MLN Evaluation and Management Service Guide 1.5 MB):
- 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.
For new patients or consultations, this can make a big difference. Without a complete past medical, family and social history (PFSH), it is impossible to document a comprehensive history. This renders a level 4 or 5 new patient office visit or consult unobtainable based on the required components.
In order to ensure proper credit is given, it is recommended to document either your positive findings relating to the patient’s medical, family, or social history, or at least document a pertinent negative finding: “FHx denies cardio diseases.” This will avoid any confusion that could be caused by use of the phrase “noncontributory.”
What is acceptable if the patient is unable to provide history?
If the history is unobtainable from the patient or any other source, the record should describe the patient’s condition or circumstances which preclude obtaining the history. Example- Family History: Patient is adopted and FHx unknown.
Before you finalized your note, ask yourself where’s the PFSH?