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Young Ophthalmologists
E&M Documentation Requirements, Part 2: A Look at Past, Family and Social History
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Ophthalmologists are more likely to be audited on exam documentation than on tests or surgical procedures. It is therefore imperative that documentation meets the payer requirements each time an exam code is billed. It’s also necessary for both risk management and coding compliance.

E&M documentation is broken down into history, exam and medical decision making. Last month, YO Info detailed the first portion of the history component, the ‘review of systems.’ This month, we’ll take a look at the second piece of the puzzle, the past, family and social history (PFSH).


Physicians should first determine which PFSH questions are medically necessary to document. This determination may be based on, but not limited by, any of the following.

Past History

  • Prior illnesses or injuries
  • Prior operations
  • Prior hospitalizations
  • Current medications (Note: Documenting these is part of the criteria for reporting Physician Quality Reporting System PQRS measure 130)
  • Allergies
  • Age-appropriate immunization status

Family History

  • The health status or cause of death of parents, siblings and children
  • Diseases or eye problems of family members that may be hereditary or place the patient at risk, e.g., family history of diabetes, glaucoma, strabismus, amblyopia, cataracts before age 50 and age-related macular degeneration

Social History

  • Marital status and/or living arrangements
  • Current employment (helpful for glasses selection/needs)
  • Use of drugs, alcohol or tobacco (Note: Documenting this is part of the criteria for reporting PQRS measure 224)

For practice-specific examples of PFSH questionnaires, visit the American Academy of Ophthalmic Executives’ Practice Forms Library.

The Two Levels of PFSH
You must cover all three histories for a new patient or consultation. This is known as a complete PFSH.

For an established patient, you should document at least one of the three histories. This is known as a pertinent PFSH. Often it is only medically necessary to review an established patient’s medications.

Additional PFSH Facts

  • In the hospital setting, physicians must obtain the PFSH from the patient or a family member or gather as medically indicated from the patient’s chart notes.
  • For established patient visits, often it is only medically necessary to review the patient’s medications in addition to one other component from the family or social history.
  • It is acceptable to review the former PFSH and note any changes as well as the date of the previous PFSH.
  • Collection of the PFSH data does not have to be performed by a physician. It is acceptable to have staff capture the information as long as the physician documents that they reviewed and commented on pertinent findings.

Next month, YO Info will take a look at the final piece to the history component of E&M documentation — the chief complaint and elements to the history of the present illness, known as the HPI. To have your own examples of chief complaints and HPIs considered for inclusion in the article and checked for audit review, email with subject line “YO Info.”

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About the author: Sue Vicchrilli, COT, OCS, is the Academy’s coding executive and the author of EyeNet’s “Savvy Coder” column and AAOE’s Coding Bulletin, Ophthalmic Coding Coach and the Ophthalmic Coding series. Jennifer Arbuckle, CPC, OCS, is an Academy coding specialist whose background includes coding, billing, compliance and reimbursement in both a small private practice and a large academic medical institution.

Academy members: login to read or make comments on this article.