Ophthalmology and Optometry Coding Alert

Question: Our physicians often can't bill a higher E/M code because they don't have an appropriate history. Do you have any tips for how we can improve their history documentation?

Codify Subscriber

Answer: You should sit down with your physicians and explain the importance of a robust history in E/M code selection, and let them know that you may have to downcode claims - which costs the practice money - if the history is not documented properly.

Medicare and CPT^® both recognize four levels of history for an E/M service: problem-focused, expanded problem-focused, detailed, and comprehensive. The chief complaint and related history of present illness (HPI) tend to be the areas where ophthalmologists document the most. The patient intake form usually covers the review of systems (ROS) and past, family and social history (PFSH). The patient usually completes this form on his own or with a nurse's help.

The chief complaint is a concise statement explaining why the patient is in the physician's office. The HPI is a more thorough description of the patient's chief complaint. It will include important elements such as location, quality, severity, duration, timing, context, modifying factors, and associated signs and symptoms.

A very brief sentence can convey several of these elements at once. A patient who complains of sharp pain (quality) in his left eye (location), which occurs after driving (context) and has been happening for the past six weeks (duration), has already given you an extended HPI because it includes four elements.

If the doctor merely documents eye pain that started six weeks ago, however, he qualifies for only two elements, reducing the HPI to "brief." Because you need to document an extended HPI to report codes 99203, 99204 and 99205, you would have to report 99201 or 99202 based on your documentation of only two elements for this visit.

The ROS consists of the positive and negative responses the patient gives to a series of questions designed to inventory the systems of the body. Most of the time, it is part of the patient intake form.

Because the patient intake form is an effective guide to document the ROS, ophthalmologists can usually quickly review the systems needed for the comprehensive ROS. To indicate that he performed an ROS, however, the doctor should note his review of the form in the patient's medical record and note any significant findings, and initial and date the patient information form.

The final aspect of the history is the PFSH, which is a review of the patient's experience with illnesses, injuries and treatments as well as age-appropriate questions about past and current activities (marital status, occupation, and use of drugs, alcohol and tobacco). The patient probably answered many of these questions on the patient information form. Again, the doctor should indicate in both the patient's record and the patient information form that this area was discussed during the visit.