Ophthalmology and Optometry Coding Alert

Question: A new patient visits the ophthalmologist with a chief complaint. I don't have a review of system (ROS) or full history because the doctor didn't document a history of present illness (HPI). He did include a brief HPI in the medical assessment that I credited toward the chief complaint. The physician completed an extended, problem-focused exam and medical decision making of low complexity. Can we bill for this encounter?Minnesota SubscriberAnswer: The AMA/CMS Documentation Guidelines state: "The CC, ROS, and PFSH may be listed as separate elements of history, or they may be included in the description of the history of the present illness." Review the brief HPI information the physician documented to determine if the statement contains both elements of a CC (chief complaint) and HPI. Accordingly, the ophthalmologist must document the HPI, exam (with the exception being vitals, which an ancillary staff member can document), and the medical [...]