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Young Ophthalmologists
E&M Documentation Requirements, Part 3: The Chief Complaint and Elements to the History of the Present Illness
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Ophthalmologists are more likely to be audited on exam documentation than on tests or surgical procedures. It is therefore imperative that documentation meets the payer requirements each time an exam code is billed. It’s also necessary for both risk management and coding compliance.

E&M documentation includes the history, exam and medical decision making. Over the last two months, YO Info has taken a look at the first two portions of the history component, review of systems and past, family and social history. This month, we’ll look at the third and final piece of the puzzle, the chief complaint and elements of the history of the present illness. These two components provide the reason for the encounter and indicate what elements of the exam are medically necessary to perform.


Chief Complaint
The chief complaint is the focus of the exam. If the patient has several complaints, document them in order of highest to lowest medical risk. For example, consider the elements of the exam performed when the patient complains of red eyelids that itch, and compare them to the elements of the exam performed when the second complaint is that the vision in the left eye has become progressively worse over the past month. Because the second complaint might carry the greatest medical risk, it should be listed first.

Note: When the primary diagnosis is blepharitis, commercial payers might downcode a higher level of exam.

The chief complaint does not have to be documented in the patient’s own words unless it provides helpful information, such as in the complaint of dry eyes: Eye discomfort OU X 2 wks. Feels like “crushed potato chips.” Artificial tears and ointments no lasting relief.

History of the Present Illness
The history of the present illness (HPI) provides a chronological description of how the patient’s present illness developed, from the first sign or symptom to the present.

CPT guidelines recognize the following eight components of the HPI:

  1. Location. What is the site of the problem? Is it unilateral or bilateral?
  2. Quality. What is the nature of the pain? Is it constant, acute, chronic, improved or worsening?
  3. Severity. Describe the pain or redness, for example, on a scale of 1 to 10, with 10 being the worst.
  4. Duration. How long has the problem been an issue?
  5. Timing. Is the problem worse in the morning or evening, or is it constant?
  6. Context. Is it associated with any activity?
  7. Modifying factors. What efforts has the patient made to improve the problem? Heat? Artificial tears? Other?
  8. Associated signs and symptoms. Is the problem causing blurred vision? Headache? Twitching? Excessive tearing?

The HPI is brief if one to three elements are documented and extended if four to eight elements are documented. CPT codes 99204, 99205, 99214 and 99215 all require an extended HPI.

Negative responses count when they are pertinent to the chief complaint, such as in the example of growths below. Negative responses don’t count when they are not pertinent to the chief complaint and/or are often cloned from exam to exam (e.g., the case of floaters below).

Documentation Type of HPI
Brief Extended
CC: Patient complains of red eye.
HPI: Limited to right eye (location). Worse in the morning (timing).
CC: “Growths”
HPI: Right and left lower lids (location). X 3 weeks (duration). Increasing in size (quality). No discharge or pain (associated signs/symptoms).
CC: Floaters OU
HPI: No headache, no itching, no tearing (not signs/symptoms associated with CC).
CC: Patient complains of red eye.  
Began two days ago (duration). Limited to right eye (location). Worse in the morning (timing). Lids are stuck shut with discharge (associated signs/symptoms).

Chronic or Inactive Conditions
For established patients only, documenting the status of some chronic or inactive conditions may qualify for an extended HPI. For example, the patient complains of:

  • Cataracts: distance vision worse since exam six months ago.
  • Dry eyes: condition improved with consistent use of artificial tears.
  • Blepharitis: condition improved with lid scrubs.

Audit Outcomes
As reported to the Academy, inadequately documented history components were the primary reason payers downcoded claims in an audit. The chief complaint, HPI, review of systems and past, family and social history all must be documented to support the level of E&M code you submit.

To have your own examples of CCs and HPIs checked for audit review, email with subject line “YO Info.”

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About the author: Sue Vicchrilli, COT, OCS, is the Academy’s coding executive and the author of EyeNet’s “Savvy Coder” column and AAOE’s Coding Bulletin, Ophthalmic Coding Coach and the Ophthalmic Coding series.

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