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Young Ophthalmologists
Avoiding an Audit: History-Taking and the Components of the Chief Complaint
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Simply hearing the word “audit” can cause anxiety in any physician … and with good reason! Yet, there are simple steps you can take to protect yourself.

For example, did you know that the number one reason physicians don’t do well in a third-party payer audit is due to an inadequate history to support the level of documentation billed — particularly in a new patient exam?  


To prevent this from happening to you, let’s review the chief complaint and the three components of history-taking in E&M (evaluation and management) coding. The key to accomplishing this successfully is to record the information to meet the payer requirements.

First and foremost, the chief complaint drives the exam. For example, if the patient complains about a bump on the upper eyelid, the elements of the exam are limited to that area, so long as the visual acuity is within normal limits.

You don’t have to use the patient’s own words verbatim unless the descriptive terms support the documentation. For example, eyes are so dry, feels like “crushed potato chips” in them.

The next step is to obtain key elements of the history of the present illness (HPI). When I was trained as a technician, the doctor asked me to:
  • First — Identify the eye(s) in which the problem is located.
  • Second — How long this has been a problem?
  • Third — Is it associated with any activity?
  • Fourth — Is there anything that makes it better or worse?
This direction has assisted me in my efforts to teach proper documentation techniques.

Next, for the HPI, you’ll need a chronological description of the development of the patient’s present illness from the first sign or symptom to the present. CPT guidelines recognized seven dimensions of the HPI:
  1. Location: What is the site of the pain or discomfort? Is it unilateral or bilateral?
  2. Duration: How long has the issue been a problem?
  3. Context: Is it associated with any activity?
  4. Modifying factors: What effort has the patient made to improve the problem? Heat? Artificial tears? Other?
  5. Quality: What is the nature of the pain? Is it constant, acute, chronic, improved or worsening?
  6. Severity: Describe the pain or redness on a scale of 1 to 10, with 10 being the worst.
  7. Associated signs and symptoms: Is it causing blurred vision, headache or twitching?
Finally, there are two common types of HPIs. A brief HPI includes one to three documented elements.
  • Good example: Patient complains of red eye. Limited to right eye. Worse in the morning.
  • Not-so-good example: 85-year-old WF for cataract evaluation OS.
An extended HPI included four to eight documented elements.
  • Good example: Patient complains of red eye. Began two days ago. Limited to right eye. Worse in the morning. Lids are stuck shut with discharge. Artificial tears do not relieve symptoms.
  • Not-so-good example: Glaucoma evaluation OU. Lids feel about the same as last visit.
Often patients have more than one chief complaint. The person obtaining the information should then list them in order of importance.

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About the author: This article was adapted from an article that appeared in the February 2010 issue of Coding Bulletin. It was written by Academy Coding Executive Sue Vicchrilli, COT, OCS.

Academy members: login to read or make comments on this article.