Wiki HPI for Eye E/M

[TiffanyM101]

I have a provider that is questioning if we still need to use HPI as an element for the 92 codes. We are not sure if this needs to be apart of our exam for these codes. Our doctor believes that history could be past medical history, family history, social history, and/or ROS, therefore he feels we should not have to document HPI. Can someone please let me know what you are doing at your clinic or if there is documentation somewhere that will define this better?

 

[Cheezum51]

Nothing changed this year as to the requirements for the 92 codes for eye exam services. Personally, I feel that the CC, combined with the HPI, is one of the most important portions of the exam which can show medical necessity for the visit to be billed medically. I still encourage my clients to include 4 HPI elements in any medical eye exam.

Tom Cheezum, OD, CPC, COPC