Ophthalmology and Optometry Coding Alert

Question: Must the ophthalmologist take a patient's history, or can a tech or other nonphysician staff take the history prior to the ophthalmologist meeting the patient?


California Subscriber

Answer: Any employee can take portions of the history. In fact, the E/M service documentation guidelines state that ancillary staff may record the review of systems (ROS) and/or past family social history (PFSH). Although nurses often record this information, a front-desk staff member may even perform the function.

Experts warn: There is a difference of opinion on whether a staff member can document the history of present illness (HPI). Although the documentation guidelines clearly state that staff can document ROS and PFSH, they do not specify HPI, nor do they state that the physician is responsible for the HPI.

However, in a 1997 AMA/CMS workshop on E/M documentation, presenter Bart McCann, MD, who was the executive medical director for CMS at that time, provided the following guidance: "The physician must write an HPI statement. It is understood that residents and other ancillary staff may collect some of this information, but this does not absolve the physician of the duty to verify the information and summarize the HPI statement himself."

Be careful: Most experts agree in recommending that the physician initial the information to prove that he reviewed it. The ophthalmologist must sign the patient's chart and must indicate that he reviewed the history notes.

Documentation should include a notation supplementing or confirming the information that others recorded. Make sure the ophthalmologist signs off on any incident-to services, such as 99211 (Office or other outpatient visit for the evaluation and management of an established patient ...), as well as higher-level E/M services (for instance, 99212-99215).

Advice for You Be the Coder and Reader Questions provided by Maggie M. Mac, CMM, CPC, CMSCS, consulting manager for Pershing, Yoakley & Associates, Clearwater, Fla; and Raequell Duran, CPC, president of Practice Solutions, Santa Barbara, Calif.