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Young Ophthalmologists
E&M Documentation Requirements, Part 4: The Exam
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E&M documentation includes the history, exam and medical decision making. Over the past few months, YO Info has taken a look at the three elements of the history — review of systems, past, family and social history and the chief complaint and elements of the history of the present illness.

This month, we turn our focus to the eye examination, which is comprised of 12 elements. These elements are performed as medically indicated by the patient’s chief and any specific complaints. Since 1997, the 12 elements have been specialty specific. For example, the exam elements for a patient with a complaint of an itchy, burning upper eyelid are different from those of a patient complaining of floaters in their vision.

Examination Elements

1. Visual acuity

  • Does not include the determination of refractive error (CPT code 92015 Determination of refractive state)

2. Gross or confrontation visual fields

  • Must be performed in the lane in order to count; automated perimetry does not substitute as an element of the exam

3. Extraocular motility

  • Includes alignment and primary gaze

4. Conjunctiva

  • Bulbar and palpebral

5. Ocular adnexa

  • Lids, lacrimal gland, lacrimal drainage, orbits and preauricular nodes

6. Pupil and iris

  • Size, shape, direct and consensual reactions and morphology

7. Cornea — slit-lamp exam

  • Tear film, epithelium, stroma and endothelium

8. Anterior chamber — slit-lamp exam

  • Depth, cells and flare

9. Lens

  • Clarity, anterior capsule, posterior capsule, cortex and nucleus

10. Intraocular pressure

11. Optic nerve/discs

  • Cup-to-disc ratio, appearance and nerve fiber layer

12. Retina and vessels

  • Examination through dilated pupils, unless contraindicated

Level of Exam Determination
The level of exam depends on the number of elements documented.

1–5 elements
Problem-focused exam
6–8 elements
Expanded problem-focused exam
9–12 elements
Detailed exam
The 13th element is documentation of orientation to time, place, person and mood and affect Comprehensive exam

Detailed vs. Comprehensive Exam
The difference between a detailed and a comprehensive exam is the addition of the 13th element, the documentation of orientation to time, place, person and mood and affect.

Unable to Obtain
Due to trauma, infection or the age of the patient, you may sometimes be unable to obtain some components of the exam. Document the reason for not obtaining those components to get credit as if the exam element was performed.

Dilation Requirements
Unless contraindicated, new patient exam codes 99204 and 99205 and established patient exam code 99215 require you to document dilation.

Next month, we’ll focus on the YO coding course recommendations in Chicago.

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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.