# NEED HELP!!! How do you code this E/M? Ophthalmology



## jwschroeterjr@gmail.com (Mar 1, 2011)

CHART NOTE #15
In March 20xx, a 67-year-old woman moved to a new region of the country Over the preceding 18 months, she had noticed increasing difficulty with glare when driving at night. The situation became intolerable once she was faced with driving in a new area. She sought the advice of an ophthalmologist. She noted that her change in vision had not been associated with pain, nor had there been any flashes or floaters. Her previous ophthalmologic history was entirely normal except for using a near-sighted spectacle correction since her teen years. The power of these glasses had recently been increased. A complete past family and social history review revealed that the patient was retired and lived alone. She felt it crucial to maintain her driving capability and independence. Her past medical history included hypertension and a hospitalization five years previously for a complicated myocardial infarction. Review of her numerous past medical records indicated she had been symptom free since recovery from her myocardial infarction· She admitted to no other medical abnormalities. She took a blood pressure medication and knew of no drug allergies. 
A comprehensive ophthalmologic examination was performed. This included determination of visual acuity with correction at distance and near. A refraction was performed. The best corrected visual acuity was 20/20 in the right eye but 20/100 in the left eye. Near correction required a +2.50. External ocular structures, as well as the pupil were examined. There was normal ocular motility Slit-lamp examination was normal except for detection of a significant posterior subcapsular cataract in the left eye. Intraocular tensions and visual fields were normal. An ophthalmoscopic examination with pupillary dilation was performed. There were several areas of peripheral retinal degeneration noted. These were most consistent with paving stone degeneration. There was no evidence of macular degeneration. The patient was told that she had a visually significant cataract and because of her functional requirements, cataract surgery was suggested.


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## FTessaBartels (Mar 4, 2011)

*What do YOU think*

jwschroeterjr ... you have a number of these scenarios where you are begging for help in coding chart notes.

We are happy to help you understand how to determine levels of E/M and code for services. However, I think you need to take a shot at coding these yourself.

Tell us what you think, and where your confusion lies.

Be specific ... for example: * I think this is a detailed history, but I'm not sure if I can count "denies pain" as an associated sign/symptom for the HPI?  *

Just asking me to give you a code is having me do your job for you. 

Hope that helps.

F Tessa Bartels, CPC, CEMC


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## ehamle (Apr 27, 2011)

FTessaBartels said:


> jwschroeterjr ... you have a number of these scenarios where you are begging for help in coding chart notes.
> 
> We are happy to help you understand how to determine levels of E/M and code for services. However, I think you need to take a shot at coding these yourself.
> 
> ...


Can you help me then please, I am thinking that the code for this is 99204 (comprehensive ophthalmologic examination) and then the codes 362.61 and 366.9 because cataract is unspecified; maybe related to age (senile). did I miss anything?


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