tci Part B Insider - 2011 Issue 16

Aspects of PFSH

Per CPT®, past medical, family and/or social history is divided into three subsections. 1. Past medical history includes the patient's experience with illnesses, operations, injuries, and treatments, says Leah Gross, CPC, coding lead at Metro Urology in St. Paul, Minn., including:prior major illnesses and injuries prior operations prior hospitalizations current medications allergies age-appropriate immunization status age-appropriate feeding/dietary status. Examples: "Patient has spina bifida; patient had a kidney stone episode 12 years ago; patient is allergic to penicillin; patient had a thyroidectomy in 2009."2. Family history includes a review of health-related events in the patient's family, including:health status or...

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