Correction: Due to an editing error, this article had previously reported that E&M code 99213 can be reported for this chart. The correct E&M code is 99214.


It is a sad reality that insurance companies recoup a substantial amount of money from post-payment audits. This raises the question, “How safe is your cash?” The answer depends, in large part, on what’s in your charts.

Over the next few months, EyeNet will tackle some of the most common types of patient encounter. Using data from real-life charts, you will see how claims should be supported by documentation of the 1) medical history, 2) exam and 3) medical decision-making.

What’s in the Chart?

An established patient with diabetes was seen for a follow-up exam.

History. Chief Complaint: Blurry vision. History of Present Illness (HPI): Blurriness in both eyes [location], especially in the morning [timing] (both distance and near) [context], for two months [duration]. “It clears as the day goes on.” [associated signs and symptoms]. Review of Systems (ROS): Eyes, endocrine and allergic. Past (PH), Family (FH) and Social (SH) History: PH—blood sugar had been 104 mg/dl for several days; it usually ranges from 104–140 mg/dl. FH—none documented. SH—none documented.

Examination. Twelve elements of the exam were performed through dilated pupils. The patient’s orientation and mood also were documented.

Medical decision-making. The chart notes included “Diabetes without retinopathy,” “Return as necessary or in one year” and “Recommend glasses Rx change.” It is signed by the doctor.

What Code Can You Use?

Type of history. In this case, the patient’s HPI has five elements (location, timing, etc.), which places it within the range of an “extended” HPI (4 to 8 elements). ROS has three elements, which counts as “extended” (2 to 9 elements). PFSH includes PH, but not FH or SH, and is therefore “pertinent.” By reviewing the position of HPI, ROS and PFSH on the table below, you can see that this chart supports a “problem detailed” type of history.

Type of exam. This chart supports a “comprehensive” exam.

Type of decision-making. The type of problem is “established problem: stable,” the test ordered/reviewed was a refraction, and the table of risk (see “Additional Resources”) indicates a low level of risk. This points to a “low” level of medical decision-making.

Summary. This combination of a “problem detailed” history, a “comprehensive” examination and a “low” level of medical decision-making supports use of E&M code 99214 plus, for the refraction, CPT code 92015 (or Eye code 92014 plus 92015).

Additional Resources

If you’re not confident in the documentation requirements for E&M codes (99XXX) or Eye codes (92XXX), it is best to study all the resources available to you. You will need more than the AMA’s CPT code book. Find specific information at www.cms.hhs.gov or in the AAOE’s Evaluation and Management and Eye Code Documentation Coding Module (look for product “012373” at www.aao.org/store).

TYPE OF HISTORY. Circle the HPI, ROS and PFSH. Whichever of these is farthest to the left determines the type of history; in this case, "Problem detailed."