Ophthalmology and Optometry Coding Alert

Question: When we determine an E/M code, the chart we use to select the level of history includes identifiers. For example, to report a problem-focused history, documentation should show a history of present illness (HPI), no review of systems (ROS), and no past, family and/or social history (PFSH). What should we do if the levels of HPI, ROS and PFSH don't match the chart? How should we determine the levels?

Louisiana Subscriber Answer: You should select the level of history according to the elements present in the ophthalmologist's documentation (HPI, ROS, PFSH).
 
The components must meet all of the requirements for a specific level for you to submit a claim for that specific level. If the patient lacks one of the elements, your choice depends on the element the chart is missing.
 
Example: A detailed history requires a minimum of four HPI elements (or the status of three or more chronic conditions when using 1997 guidelines), at least two ROS, and a comment about one of the "histories" (past, family or social).
 
If the documentation provides a comment about only one ROS, such as the eyes, the documentation does not support the requirements for a detailed history. Therefore, you should select an expanded problem-focused code (such as 99213, Office or other outpatient visit for the evaluation and management of an established patient ...) because the physician has met ROS requirements for this level (one to three HPI elements, one ROS, zero PFSH).