Ophthalmology and Optometry Coding Alert

Ensure you have documentation of each system -- or prepare to assign a lower code.Level-four and level-five office visits are not uncommon in an ophthalmology practice, but if you incorrectly capture the history, exam, and medical decision-making (MDM), you will miss out on the higher level codes you could report.Background: All documentation requires a chief complaint (CC) (which may be captured as part of the history), history, examination and MDM. The history component of an E/M service is further broken down into three elements: history of the present illness (HPI), review of systems (ROS) and past, family, social history (PFSH). Most often, physicians do not document the ROS element completely although the work in obtaining this information was performed. This may be because pertinent negatives responses were not documented or lack of the "all systems were reviewed and are negative" statement. The resultant level of E/M service may mean selection of [...]