Ophthalmology and Optometry Coding Alert

Make your ophthalmologist's job easier by letting the patient or nurse document the history.

If your ophthalmologist glosses over a patient's past family and social history (PFSH), you may be missing out on up to $69 per E/M.

Accurately counting the number of PFSH items could result in more money for an encounter, because the top-level E/M codes require PFSH elements. Learn these three quick tips to ensure your ophthalmologistis capturing, and you're recognizing, every history component the patient mentions.

Determine the Level of PFSH

For coding purposes, the history portion of an E/M service requires all three elements -- history of present illness (HPI), review of systems (ROS), and past family and social history (PFSH).

Therefore, the PFSH helps determine patient history level, which has a great effect on the E/M level you can report. However, medical necessity for performing a comprehensive history must be evident in the patient progress notes, advises Maggie M. Mac, CPC, CEMC, CHC, CMM, ICCE, Director of Network Oversight, Mount Sinai Medical Center Compliance Department in New York City. "It may well be a standard of care to obtain a comprehensive history with new patients or patients who have not been seen for a year or more, but it is obvious that a comprehensive history is not necessary if the patient is being seen only days or weeks apart," she says. If you do not know the PFSH level, you will be unable to decide which level of E/M code you should use on the claim.

There are three levels of PFSH: N/A, pertinent, and complete, says Leah Gross, CPC, coding lead at a practice in St. Paul, Minn.

Pertinent: To reach a detailed level of history for the encounter, you need a pertinent PFSH. According to Medicare's Documentation Guidelines for E/M Services, you need at least one specific item from any of the three PFSH areas to achieve the pertinent level. When the physician asks only about one history area related to the main problem, this is a pertinent PFSH.

Complete: A complete PFSH includes, per Medicare's Documentation Guidelines, at least one specific item from two of the three areas for the following categories of E/M services:

• Established patient office/outpatient services
• Emergency department services
• Established patient domiciliary care
• Established patient home care.

For all other E/M services, a complete PFSH includes at least one specific item from each of the three areas.

Don't miss: "Keep in mind that it is not necessary to perform the PFSH for subsequent hospital visits or subsequent nursing facility care," notes Mac.

Pointer: You need only one element of PFSH to receive some credit for the history component of the encounter. Best bet: "Document it all. You never know what may be pertinent to the patient's current situation!" Gross advises.

Choose a Code Based on PFSH Element Requirement

Once you determine the level of PFSH your physician's documentation contains, you can see which codes that history element supports.

Beware: If your physician does not document any PFSH elements, you can only reach an extended problemfocused level of history, warns Barbara J. Cobuzzi, MBA, CPC, CENTC, CPCH, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a consulting firm in Tinton Falls, N.J. That means the highest codes you'll be able to report are a level-two new patient code (99202) or a level-three established patient code (99213). Reporting 99202 pays $71.01 (the national unadjusted rate based on the Medicare Physician Fee Schedule assignment of 2.09 RVUs times the 2011 conversion factor of 33.9764) and 99213 pays $68.97 (2.03 RVUs).

A pertinent PFSH supports a detailed history level. With detailed history you can report a level-three new patient code (99203) and a level-four established patient code (99214). You'll earn $102.95 for 99203 (3.03 RVUs) and $102.27 (3.01 RVUs) for 99214.

To get to level-four and five new patient visits and level-five established patient visits, you need to have a comprehensive level of history, Cobuzzi says. To do that, you must find a complete PFSH is supported in your physician's documentation. If you can achieve 99204 or 99205, you'll earn $158.33 (4.66 RVUs) and $197.06 (5.8 RVUs), respectively. You can expect $137.60 (4.05 RVUs) for 99215 -- nearly $69 more than if you're forced to report 99213 because you didn't have enough PFSH.

Note: Since established patient office visits require two of three key components, a higher level service is stillpossible based on the service's examination and medical decision making (MDM) types. "For an established patient, you may decide to leave history off and count only the exam and MDM and then just have the low history," Cobuzzi says. "So, if you have a weak history, you might still reach the higher level E/M."

Count Unchanged PFSH in Current Encounter

Based on E/M guidelines, if a patient's PFSH has not changed since a prior visit, your physician doesn't have to document the information again. He does, however, need to document that he reviewed the previous information, noting any changes, and note the date and location of the initial earlier acquisition of the PFSH. Some payers will give no PFSH credit if you overlook one of these criteria.

In writing: Both the 1995 and 1997 E/M documentation guidelines include the following: A ROS and/or a PFSH obtained during an earlier encounter does not need to be re-recorded if there is evidence that the physician reviewed and updated the previous information. This may occur when a physician updates his or her own record or in an institutional setting or group practice where many physicians use a common record. The review and update may be documented by:

• describing any new ROS and/or PFSH information or noting there has been no change in the information; and
• noting the date and location of the earlier ROS and/ or PFSH.

For example: Your physician may note, "PFSH: Same as documented in my note of January 7, 2011." If there's been a change, he should record it, such as: "PFSH: Same as documented in my note of January 7, 2011, except the patient no longer drinks alcohol."

Good news: As with the review of systems (ROS), Medicare states that either the patient or nurse can fill out a history form for PFSH. "The patient usually will get a questionnaire to fill out with these questions, and often the nurse or assistant will expand on the answers." Gross says. "However, the physician must document that he or she reviewed these answers to receive credit." As long as the physician signs the form or nurse's notes and documents that he reviewed them, you can meet the requirements for PFSH with that information.