Optometry Coding & Billing Alert

CC need not be at the very top of the note, but the OD must state it clearly.

Getting dinged on audits because you don't have a chief complaint (CC) listed at the top of your optometrist's documentation?

Medicare carriers differ regarding which staff members can document the chief complaint. Be sure to check if your carrier restricts who can record the CC.

Example: WPS Medicare, the Part B payer in four states, notes that "the 1995 and 1997 Documentation Guidelines do not address who can record the chief complaint [CC]. WPS Medicare will allow the chief complaint when recorded by ancillary staff. However, the physician must validate the CC in the documentation."

Don't give up until you check the entire note. Although you'll benefit from a chief complaint documented clearly at the beginning of the note, Medicare doesn't require that you list it at the top.

The 1995 and 1997 CMS Documentation Guidelines indicate that the chief complaint; review of systems; and the past, family, and social history may be listed as separate elements of history, or they may be included in the description of the history of the present illness (HPI), notes Sherry Gann, CPC, with Shawnee Health Service in Carterville, Ill. "Therefore, the chief complaint can't just be anywhere on the record," Gann says. "It must either be listed separately or in the HPI."

Important: "The guidelines don't come out and say 'it must be at the top of the note,' but the guidelines are very clear that the chief complaint should not be implied but stated clearly," says Suzan Berman (Hvizdash), CPC, CEMC, CEDC, senior manager of coding and compliance in the departments of surgery and anesthesiology at the University of Pittsburgh Medical Center.

"The chief complaint should be clearly illustrated," says Berman. "Listing it among the assessment might not paint the clearest picture. There might be other issues that came out in the visit (or other conditions the clinician is concerned about as they relate to the chief complaint or the possible treatment options), but they might not be the exact complaint."

What to do: To avoid having to dig into the assessment section of the doctor's note, encourage your doctor to write "c/c" at the top of the visit notes. After this, the doctor should write a word or two explaining why the patient needs to be seen by a physician. The doctor could write simply, "follow-up for cataract," "pain in eye," or "blurred vision."

Encourage your optometrist not to write vague statements like "feeling better," "feels well," "much better," "comfortable," or "resting quietly" as the CC.

Patients generally are not aware that they need to tell the optometrist any complaints when they present for a full eye exam, experts note. And simply asking "What's the main reason you are having your eyes examined today?" will frequently generate "Just my annual exam" as a response, so optometrists will often have to ask more probing and open-ended questions.

Example: An optometrist may have to ask, "Do your eyes ever itch or feel dry?" or "Are you having any trouble seeing to drive?" to generate a complaint. Patients sometimes will not mention things they think are normal or things they think are "supposed to be that way" because of age. Occasionally patients will not mention their most serious symptom until the end of the exam, because it wasn't serious to them. This is why the case history doesn't end until the patient leaves your office.