Wiki history with eye codes

[rhotonscott]

Coding opthalmology for 9 months now and struggling with the 'history/general medical evaluation' concept of using eye codes. Some of my foreign-born docs only write in short statements (basically restating the diagnoses the techs wrote). I know to use E/M codes for follow-ups and such, and they require a true 'HPI'. My problem is I want to use eye codes when appropriate, but these doctor's observations seem more like A&P info rather than 'history/general medical evaluations'. What constitutes this info? Can I get by using the eye codes when there is limited info for this vague 'history' required to use the eye codes? I am probably the expert here where I work, so any valid documentation that would help me explain it to a future audit would help! haha!

 

[drakena74]

check with AAO website, they may have information as to what has to be documented in the charts when using vision codes.

I do know that E/M codes require more documentation in the charts the vision codes do. That is why most Ophthal & optometrists use vision codes.