Ophthalmology and Optometry Coding Alert

In CMS's eyes, this element is your ophthalmologist's duty.

You're not alone if you've read and re-read the E/M documentation guidelines in search of the definitive answer as to who can perform the history of present illness (HPI). In many practices, ancillary staff (such as an ophthalmic tech) takes the patient's past, family, and social history (PFSH) and review of systems (ROS). The ophthalmologist then obtains the HPI.

If your practice wants to verify whether this is a proper use of everyone's time, you might be hard-pressed to find the guideline in writing. Here's where to turn for guidance, and the guidelines ophthalmologists and staff need to stick to.

You may permit a staff member, or even allow the patient or patient's guardian, to record the PFSH and ROS elements. This guidance stems from the CMS-approved E/M documentation guidelines. "The ROS and/or PFSH may be recorded by ancillary staff or on a form completed by the patient," according to the 1995 and 1997 documentation guidelines for E/M services.

Don't miss: The ophthalmologist must document that he reviewed the PFSH and ROS history elements. The notation must supplement or confirm the information that others recorded, the guidelines state.

For instance, if an ophthalmologist reviews a patient-completed PFSH and ROS form, he could indicate his review "with a brief line, such as 'I reviewed the history form filled out by the patient on Sept. 4, 2007,'" says Margaret M. Maley, BSN, MS. He should also sign and date the form and retain it in the patient's medical record. There must also be a reference to the separately obtained document containing the ROS/PFSH in the documentation of the office visit by the physician.

Because the E/M guidelines create concrete PFSH and ROS recording criteria, many people look to the same place for HPI reporting information. "The guidelines have never defined if the staff was allowed to document the history of present illness," says Teresa Thompson, CPC, CMSCS, CCC, a consultant in Carlsborg, Wash.

Catch this: The absence of any HPI performer statement indicates ancillary staff does not have permission to collect the HPI, says Barbara J. Cobuzzi, MBA, CPC-OTO, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J. The E/M guidelines specifically state that ancillary staff can collect ROS and PFSH. If CMS had extended HPI permission to staff, the guidelines would have included this allowance.

In fact, physicians actually get paid for this work if the payer uses the Medicare Physician Fee Schedule. CMS explained that the E/M service code values include physician work for performing the HPI, says Mary Pat Johnson, COMT, CPC, COE, senior consultant for Corcoran Consulting Group.

Your office can involve staff in the HPI. Ancillary staff can gather preliminary information by questioning the patient regarding the CC, but the physician must confirm this information by re-writing the HPI statement with any deletions or additions. In essence, the ophthalmologist should perform the HPI by himself. In a chart audit, documentation of HPI done by anyone other than the physician does not count in determining if documentation supports the E/M code assigned.

Scribe also allowed: A physician scribe may also record the HPI as the physician dictates and performs it.

In this case, the ophthalmologist must review the information as documented, recorded, or scribed. He must also write a notation that he reviewed it for accuracy and did perform it, adding to it if necessary and signing his name, according to one carrier.

Auditors have requested information that supports the physician's HPI performance, including asking patients or staff to verify the doctor's role. To support services on post-payment review, the physician must document his involvement in obtaining the HPI, Thompson says.

Depending on your documentation system, follow these three Thompson-recommended best practices:

Written: The difference in handwriting as well as notes from the physician expanding on the information obtained from the patient can support the physician's role.

Paper templates with boxes: The physician has obtained and documented the information from the patient, which he indicates by checking a box. However, it is not appropriate to have a "check-off" box for HPI documented by the patient on an intake form, experts say. The ophthalmologist still needs to document this component completely. On the other hand, a "check-off" box may be okay for notating the review of the patient's ROS/PFSH form. There should also be a signature or initial and date line on the patient intake form for the ophthalmologist to notate his actual review of the form.

Electronic medical records: Your ophthalmologist could indicate in the note that he participated in obtaining the information. To prove this, your practice might want to implement a clinic protocol indicating that the physician is responsible for obtaining the HPI information and that ancillary staff may not document the information obtained.

Bottom line: The most efficient way of obtaining and documenting the HPI is for the ophthalmologist to perform this element of the history, experts say. It also makes more clinical sense, because this essential element will in turn determine the examination he performs and influence his medical decision making.