Answer: For certain categories of evaluation and management (E/M) services that only include an interval history, it is not necessary to record information about the past, family and social history (PFSH). Those categories are subsequent hospital care and subsequent nursing facility care.

The 2011 Current Procedural Terminology (CPT) Professional Edition, Subsequent Hospital Care page and Subsequent Nursing Facility Care page state as follows:

"All levels of subsequent hospital care (or subsequent nursing facility care) include reviewing the medical record and reviewing the results of diagnostic studies and changes in the patient’s status (i.e., changes in history, physical condition and response to management) since the last assessment by the physician."

Resource: CMS 1995 & 1997 E/M Guidelines

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