Ophthalmology and Optometry Coding Alert

In CMS's eyes, this element is your ophthalmologist's duty.You're not alone if you've read and re-read the E/M documentation guidelines in search of the definitive answer as to who can perform the history of present illness (HPI). In many practices, ancillary staff (such as an ophthalmic tech) takes the patient's past, family, and social history (PFSH) and review of systems (ROS). The ophthalmologist then obtains the HPI.If your practice wants to verify whether this is a proper use of everyone's time, you might be hard-pressed to find the guideline in writing. Here's where to turn for guidance, and the guidelines ophthalmologists and staff need to stick to.Sort Out History TerritoryYou may permit a staff member, or even allow the patient or patient's guardian, to record the PFSH and ROS elements. This guidance stems from the CMS-approved E/M documentation guidelines. "The ROS and/or PFSH may be recorded by ancillary staff or on a form completed by the patient," according to the 1995 and 1997 documentation guidelines for E/M services.Don't miss: The ophthalmologist must document that he reviewed the PFSH and ROS history elements. The notation must supplement or confirm the information that others recorded, the guidelines state.For instance, if an ophthalmologist reviews a patient-completed PFSH and ROS form, he could indicate his review "with a brief line, such as 'I reviewed the history form filled out by the patient on Sept. 4, 2007,'" says Margaret M. Maley, BSN, MS. He should also sign and date the form and retain it in the patient's medical record. There must also be a reference to the separately obtained document containing the ROS/PFSH in the documentation of the office visit by the physician.Consider Lack of Guidance as GuidanceBecause the E/M guidelines create concrete PFSH and ROS recording criteria, many people look to the same place for HPI reporting information. "The guidelines have never defined if the staff was allowed to document the history of present illness," says Teresa Thompson, CPC, CMSCS, CCC, a consultant in Carlsborg, Wash.Catch this: The absence of any HPI performer statement indicates ancillary staff does not have permission to collect the HPI, says Barbara J. Cobuzzi, MBA, CPC-OTO, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J. The E/M guidelines specifically state that ancillary staff can collect ROS and PFSH. If CMS had extended HPI permission to staff, the guidelines would have included this allowance.Count HPI Work as Part of E/M In fact, physicians actually get paid for this work if the payer uses the Medicare Physician Fee Schedule. CMS explained that the E/M service code values include physician work for performing the HPI, says Mary Pat Johnson, COMT, CPC, COE, [...]