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  • Savvy Coder

    New E/M Rules for Office Visits, Part 1: The Medically Relevant Patient History

    By Sue Vicchrilli, COT, OCS, OCSR, Academy Director of Coding and Reimbursement, With David B. Glasser, MD, Robert S. Gold, MD, FAAP, Emily P. Jones, MD, and John T. McCallister, MD

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    If you have been using the office-based evaluation and management (E/M) codes, you’ll know that the history component involves an oner­ous series of steps—but not for much longer!

    Almost gone are the days of obtain­ing and documenting a review of 10 or more body systems plus a past medical history, family history, and social history plus a chief complaint plus a minimum of four elements to the history of the present illness.

    Big changes coming. Beginning Jan. 1, 2021, Medicare is streamlining the requirements for patient history when using office-based E/M codes 99202-99215. The history will need to be medically appropriate, which means that you need to document only infor­mation that will be medically relevant for the physician. What’s relevant? This will vary depending on the nature of the patient encounter.

    This month and next month, Savvy Coder provides some typical examples seen daily in ophthalmic practices.

    Get ready with technician training. While this change to the documentation requirements is great news, technicians will need some help. In addition to giving them the AAOE’s new resources (see “Train Your Staff”), ophthalmologists should walk their technicians through the types of information that are need­ed for a medically relevant history.

    Who can obtain and document the history? Any part of the chief com­plaint or history that is recorded in the medical record by ancillary staff or the beneficiary (patient) does not need to be documented again by the billing practitioner. Instead, that person may review the information, update or sup­plement it as needed, and indicate in the record that he or she has done so.

    Cataract Example

    When patients are referred for cata­ract surgery, John T. McCallister, MD, asks that his technicians capture these details of their blurred vision.

    • Laterality: Is the blurriness in the right eye, left eye, or both?
    • Onset: Gradual or sudden?
    • Duration: When did the blurred vision start?
    • Effect on daily life: What activities are affected? Specifically ask about driv­ing, working, reading, using a computer or device, watching television, and doing crafts or other activities.
    • Glare or halos: Is the patient both­ered by glare or halos? If so, during daytime and/or nighttime? In the rain? In certain indoor lighting conditions?
    • Surgical history: Any history of refractive surgery? If so, what type of refractive surgery, when, how many times, and can we get past records?
    • Injury: Any history of trauma or other injury?
    • Eye disorders: Any concurrent eye disorders (e.g., blepharitis, diabetic retinopathy, dry eye syndrome, epiret­inal membrane, epithelial basement membrane dystrophy, glaucoma, lattice degeneration, macular dystrophy, pseu­doexfoliation syndrome, retinal tear or detachment, uveitis, etc.)?
    • Medications: Taking, or have pre­viously taken, any prostate or bladder medications? Any blood thinners?
    • Family history: Any family members with eye issues?
    • Allergies: Any medication allergies? Latex allergies?
    • Anesthesia: Any adverse reactions to anesthesia?
    • Noncovered services: What has the patient heard regarding premium IOLs and femtosecond lasers?

    Dr. McCallister is a comprehensive ophthalmologist at Northern Virginia Ophthalmology Associates, which has offices near Alexandria and D.C.

    Train Your Staff

    Conquering New E/M Documenta­tion Guidelines for Ophthalmology is now available. It combines a narrated online tutorial with an accompanying workbook. Review the step-by-step instructions, clinical examples, and worksheets, and then pass the exam section to earn an electronic certifi­cate of completion.

    To buy this coding product, visit

    Cornea Example

    There are many potential indications for a corneal transplant, such as scar­ring, endothelial failure, dystrophy, infection, and trauma. That said, David B. Glasser, MD, considers the following as medically relevant: 

    • Chief complaint: What is the prima­ry problem for which you seek consul­tation and possible surgery? What are the vision problems? Describe any pain or discomfort.
    • Laterality: Right eye, left eye, or both? If both, which is worse?
    • Duration: When did it start/how long has it been going on?
    • Cause: Do you think anything in particular caused it?
    • Onset: Did it come on suddenly or gradually?
    • Stability: Is it getting better or worse or has it been stable? If stable, for how long has it been stable?
    • Associations: Does anything in particular make the symptoms better or worse?
    • Effect on daily life: What activities does it affect? Driving, reading, any specifics?
    • Surgical history: Any past eye sur­gery? What was the surgery and when did it take place?
    • Medications: Any systemic or topical medications?

    Dr. Glasser is the Academy Secretary for Federal Affairs.

    Glaucoma Example

    Under the new rules, Emily P. Jones, MD, will be asking her technicians to document the following elements for a typical glaucoma patient:

    • Surgical history: Any history of prior eye surgeries?
    • Family history: Is there a strong family history of glaucoma with glau­coma surgeries or vision loss at an early age?
    • Medical history: Examples of perti­nent histories include:
      • A stroke resulting in homony­mous visual field defects.
      • A history of poorly controlled diabetes with renal disease, limb amputations, hospitalizations.
      • A distant history of trauma to one eye.
    • Medications: Examples of pertinent details include:
      • Any glaucoma medications that a patient took in the past but did not tolerate or did not respond to?
      • A history of asthma with use of inhalers that would make the patient a poor candidate for beta-blocker drops?
      • Long-term use of oral or inhaled steroids?
      • A history of exudative macular degeneration with intravitreal Avastin injections (which can lead to very elevated eye pressure).

    Dr. Jones is a glaucoma specialist at the Devers Eye Center in Portland, Oregon.

    Pediatric Example

    Suppose a patient is referred by his pediatrician to your practice for stra­bismus?

    Robert S. Gold, MD, FAAP, would want to make sure that the following information is documented in the patient’s record:

    • Direction of misalignment: In, out, up, or down?
    • Duration: Days, months, or years?
    • Constant or intermittent strabismus?
    • Double vision?
    • Is it better or worse at certain times of day?
    • Family history of strabismus/ambly­opia?
    • Eye history: Used glasses, patching, and/or undergone surgery?
    • Pertinent information from past history, medical history, neurologic his­tory, and genetic history (syndromes).

    And what if you’re examining an adult strabismus patient? In that case, Dr. Gold would want the technician to also document any history of diabe­tes, hypertension, vascular problems, trauma, neurologic issues, and medi­cations.

    Dr. Gold is a pediatric ophthalmologist at Eye Physicians of Central Flori­da, with offices in the Orlando metropol­itan area.

    The Eye Visit Codes

    What about the history component for Eye visit codes 92002–92014? Whether the patient is new or established, and whether the exam is limited or com­prehensive, the history documentation requirements for Eye visit codes will be the same in 2021 as they were in 2020.

    Increased E/M Payments

    Payments for office-based E/M codes—but not for Eye visit codes—are slated for a “significant” increase on Jan. 1, 2021. The Centers for Medicare & Medicaid Services (CMS) will an­nounce the size of those increases in November, when it publishes the 2021 Medicare Physician Fee Schedule. Un­fortunately, unless Congress intervenes to amend CMS’ budget-neutrality man­date, these increases in E/M payments could result in cuts to other codes (see this month’s Academy Notebook).

    What About MIPS Reporting?

    Are you participating in the Merit-Based Incentive Payment System (MIPS) this year? Depending on which quality measures you select, your technicians may need to add extra questions to their history-taking checklist. For exam­ple, this would currently be the case if you selected any of the following:

    • Measure 110: Preventive Care and Screening: Influenza Immunization
    • Measure 111: Pneumonia Vaccination Status for Older Adults
    • Measure 130: Documentation of Current Medications in the Medical Record
    • Measure 226: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
    • Measure 238: Use of High-Risk Medications in the Elderly
    • Measure 402: Tobacco Use and Help With Quitting Among Adolescents

    Many of these quality measures are likely to still be available for reporting during the 2021 MIPS performance year. For detailed descriptions of them, visit

    Further Reading

    New E/M Rules for Office Visits, Part 2: How to Document the Retina Exam (September 2020, EyeNet)

    Taking retina histories. Plus the nonoffice exam.

    New E/M Rules for Office Visits, Part 3: The Medically Relevant Exam (October 2020, EyeNet)

    Anterior segment and pediatric examples.

    New E/M Rules for Office Visits, Part 4: Cornea and Oculofacial Exams (November 2020, EyeNet)

    Cornea and oculofacial examples.