EM Coding Alert

Question: We know we can’t report an E/M code without a chief complaint, but sometimes we have trouble finding one in our optometrist’s notes. Is there a formula for this?

Mississippi Subscriber

Answer: The chief complaint should be clearly illustrated somewhere in the notes, even though it doesn’t have to be at the top of the report. To avoid having to dig into the assessment section of the doctor’s note, encourage your doctor to write “c/c” at the top of the visit notes. After this, the doctor should write a word or two explaining why the patient needs to be seen by a physician. The optometrist could write simply, “evaluate cataracts,” “pain in eye,” or “blurred vision.”

Encourage your optometrist not to write vague statements like “feeling better” or “condition improved” as the c/c.

Patients generally are not aware that they need to tell the optometrist any complaints when they present for a full eye exam, and simply asking “What’s the main reason you are having your eyes examined today?” will frequently generate “Just my annual exam” as a response, so optometrists will often have to ask more probing and open-ended questions.

Example: An optometrist may have to ask, “Do your eyes ever itch or feel dry?” or “Are you having any trouble seeing to drive?” to generate a complaint. Patients sometimes will not mention things they think are normal or things they think are “supposed to be that way” because of age. Occasionally patients will not mention their most serious symptom until the end of the exam, because it wasn’t serious to them. This is why the case history doesn’t end until the patient leaves your office.