complains of “fainting spell.” ● ROS: • Constitutional: Weight stable, + fatigue. • Eyes: + loss of peripheral vision. • Ear, nose, mouth, throat: No complaints. • Cardiovascular: + palpitations; denies chest pain; denies calf pain, pressure, or edema. • Respiratory: + shortness of breath on exertion. • Gastrointestinal: Appetite good, denies heartburn and indigestion. + episodes of nausea. Bowel movement daily; denies constipation or loose stools. • Urinary: Denies incontinence, frequency, urgency, nocturia, pain, or discomfort. • Skin: + clammy, moist skin. • Neurological: + fainting; denies numbness, tingling, and tremors. • Psychiatric: Denies memory loss or depression. Mood pleasant. Past, Family, and/or Social History (PFSH) PFSH consists of a review of three areas: 1. Past history includes experiences with illnesses, operations, injuries, and treatments 2. Family history includes a review of medical events, diseases, and hereditary conditions that may place the patient at risk 3. Social history includes 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 this 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. Page 11 of 23 MLN006764 February 2021 Evaluation and Management Services Guide MLN Booklet 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. You must document at least one specific item from two of the three history areas for a complete PFSH for these 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) ● Home care, established patient You must document at least one specific item from each of the history areas for these categories of E/M services: ● Office or other outpatient services, new patient ● Hospital observation services ● Hospital inpatient services, initial care ● Consultations ● Comprehensive NF assessments ● Domiciliary care, new patient ● Home care, new patient In this example, the patient’s genetic history is reviewed as it relates to the current HPI: ● HPI: Coronary artery disease ● PFSH: Family history reveals: • 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 Notes on the Documentation of History and Exam ● To simplify documentation of history and exam for established patients for office/outpatient visits, when relevant information is already contained in the medical record, practitioners may choose to focus their documentation on what has changed since the last visit, or on pertinent items that have not changed, and need not re-record the defined list of required elements if there is evidence that the practitioner reviewed the previous information and updated it as needed. Evaluation and Management Services Guide MLN Booklet Page 12 of 23 MLN006764 February 2021 Any part of the chief complaint or history that is recorded in the medical record by ancillary staff or the beneficiary does not need to be re-documented by the billing practitioner, and may instead review the information, update or supplement it as necessary, and indicate in the medical record that he or she has done so. are-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/E-MVisit-FAQs-PFS.pdf ● You may list the CC, ROS, and PFSH as separate elements of history or you may include them in the description of the HPI. ● You do not need to re-record a ROS and/or a PFSH obtained during an earlier encounter if there is evidence that the physician reviewed and updated the previous information. This may occur when a physician updates his or her own record or in an institutional setting or group practice where many physicians use a common record. You may document the review and update by: • Describing any new ROS and/or PFSH information or noting there is no change in the information. • Noting the date and location of the earlier ROS and/or PFSH. ● Ancillary staff may record the HPI, ROS and/or PFSH. Alternatively, the patient may complete a form to provide the ROS and/or PFSH. You must provide a notation supplementing or confirming the information recorded by others to document that the physician reviewed the