Ophthalmology and Optometry Coding Alert

Question: Our ophthalmologist lists the chief complaint for all follow-up visits using just “f/u” – we have never had an issue collecting payment but our coder is concerned that this isn’t compliant. Can you advise?

Codify Subscriber

Answer: The chief complaint is not thorough enough, and if the physician writes the same thing on every record, he could even be at risk of accusations of “cloned notes.”

First and foremost, avoid “follow-up” as a catch-all complaint. All E/M documentation must include a chief complaint, but what your ophthalmologist lists as the chief complaint may not fit your payer’s requirements. The chief complaint is considered by insurers to be a concise statement that describes the symptom, problem, condition, diagnosis, or reason for the E/M encounter. It is typically stated in the patient’s own words. An example for ophthalmology practices might include worsening vision problems or pain in the eye. Just stating “follow-up” is not appropriate.

In addition, whether the cloned documentation is handwritten, the result of a pre-printed template, or use electronic health records, cloning of documentation will be considered misrepresentation of the medical necessity requirement for coverage of services. Therefore, you should never have documentation with the same information listed over and over again, because this could create compliance issues. Speak with the physician in question and educate him on appropriate coding techniques to avoid this issue in the future.