Optometry Coding & Billing Alert

Question: Are there any official coding rules or regulations that state how often a patient's history needs to be updated? I know patients are -new- if they are not seen in three years. Is the history also good for three years?


New York Subscriber

Answer: There are no specific limits on how often you need to obtain a complete new history for a patient you see in the office.

From an E/M documentation standpoint, for you to report an established patient office visit code, you must meet two of the three elements of history, physical examination (PE), and medical decision-making (MDM).

In order for any of the elements of history (history of present illness [HPI]; review of systems [ROS]; and past, family and social history [PFSH]) to qualify for documentation of a given level, there must be evidence that it was either performed again or reviewed and updated.

If one of the two key components of the E/M service is the history, most experts agree that the optometrist should personally obtain the HPI, even though the E/M guidelines do not explicitly state this. In fact, each time a patient comes into your office you should again obtain the HPI. Simply reviewing a previously obtained HPI is not sufficient for documentation of a new HPI during a new encounter. 

If someone besides the optometrist obtains the ROS and PFSH, the optometrist may note the findings, add further information, and countersign and date the encounter. He is not obliged to repeat this part of the history.

Advice for Reader Questions and You Be the Expert contributed by David Gibson, OD, FAAO, practicing optometrist in Lubbock, Texas; and Charles Wimbish, OD, president of Wimbish Consulting Group in Martinsville, Va.