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Ophthalmology and Optometry Coding Alert

E/M Coding:

Stop Forfeiting Level Four and Five E/Ms With 3 PFSH Tips

Published on Tue Jun 07, 2011

Make your ophthalmologist's job easier by letting the patient or nurse document the history.If your ophthalmologist glosses over a patient's past family and social history (PFSH), you may be missing out on up to $69 per E/M.Accurately counting the number of PFSH items could result in more money for an encounter, because the top-level E/M codes require PFSH elements. Learn these three quick tips to ensure your ophthalmologistis capturing, and you're recognizing, every history component the patient mentions.Determine the Level of PFSHFor coding purposes, the history portion of an E/M service requires all three elements -- history of present illness (HPI), review of systems (ROS), and past family and social history (PFSH).Therefore, the PFSH helps determine patient history level, which has a great effect on the E/M level you can report. However, medical necessity for performing a comprehensive history must be evident in the patient progress notes, advises Maggie M. Mac, [...]
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