Current documentation guidelines for all families of evaluation and management (E/M) codes require a medically relevant history and examination. You are no longer required to perform a complete review of systems and count history of present illness or exam elements.

What is a "medically relevant" history and exam? It is determined by the treating physician, who considers why the patient comes in for care on the day of service. Although a comprehensive review of systems is no longer required, facets of patient history gathered in this process may still be important for the physician to know. A best practice tip is to make a list of frequently treated diagnoses and ask the physician(s) what they need to know to adequately care for the patient.

A medically relevant history includes a chief complaint, documenting which eye(s) is affected, what makes it worse or better, ocular history, and other systemic diseases, etc. Additional documentation may include Merit-Based Incentive Payment System (MIPS) quality measures that the practice reports, such as whether the patient uses or has used tobacco and a medication reconciliation. 

The medically necessary exam elements are also determined by the treating physician and can be dependent on the chief complaint or current care plan. Ensure that the documentation includes all information needed to treat the patient and meets payer policy requirements.

Comprehensive documentation is key to determining and being properly reimbursed for E/M services. To improve successful documentation of patient encounters the Academy offers Documentation Training for Clinical Teams and features E/M guidance in chapter 4 of Fundamentals of Ophthalmic Coding.