Wiki Coding for Opthalmology

[dclark7]

I'm new to opthalmology coding. One of the elements for the opthalmological services codes (92002, 92004, 92012 & 92014) is "General Medical Observation". Could someone explain to me what needs to be documented to meet this element? The notes I've been looking at will say something like cc: itchy eyes, then go on to say pt c/o of itchy eyes for 2 days. The provider then goes into his exam, but I don't se any medical observations.

I've tried some of the websites and was also given some seminar handouts, but none of them addresses the general medical observation element. Any help would be appreciated, i'm supposed to give feedback to the docs and I want to understand this prior to speaking with them.

Doreen Clark,CPC

 

[vpcats]

It's similar to the Review of Systems or the neuro/psych elements of the E/M codes.
How does the patient look? What does the doctor observe clinically?

 

[dclark7]

Thank you for your reply.