Ophthalmology and Optometry Coding Alert

Question: When a new patient fills out the medical history form, should both the patient and the physician sign the form as part of the patient's chart documentation?

Ohio Subscriber

Answer: When practice behavior comes under compliance scrutiny, it is always better to be safe than sorry.

For Medicare patients, it is a good idea to have the physician confirm the patient's provision of medical history and present symptoms (documented and signed in the forms completed by the patient prior to seeing the physician). It is up to the physician whether he prefers to sign or initial the forms.

For third-party payers and patients other than Medicare patients, review the documentation and billing guidelines for specific regulations that address physician confirmation requirements for new patient medical history. Don't assume that because one carrier does not require the physician's signature that no carriers do you can be sure the carriers will have individual policies.