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.
Ophthalmology practices can use both E&M and Eye codes, but each has its own documentation requirements. This month, YO Info will focus on one piece of the E&M puzzle — the review of systems.
Basic Elements
E&M documentation involves three components:
- History
- Exam
- Medical decision making
The history component entails three parts:
- Review of systems ROS
- Past, family and social history PFSH
- Chief complaint and elements to the history of the present illness HPI
History, Review of Systems
For the first part, review of systems, 14 areas comprise the review. Many practices wisely provide sub questions rather than the general term. What sub questions to ask is completely up to the needs of the ophthalmologist. Systems to review:
1. Eyes
- Sudden loss or change in vision
- Burning or itching; excessive tearing
- Redness
- Discharge
- Swelling of lid or growth
- Other
2. Constitutional
3. Ears, nose, mouth and throat
- Sinus infection
- Deafness
- Dry mouth
- Other
4. Cardiovascular
- Heart Attack
- Chest Pain/ Angina
- Congestive Heart Failure
- Irregular Heart Beat
- High Blood Pressure
- Low Blood Pressure
- Pacemaker/defibrillator
- High cholesterol
5. Respiratory
- Asthma
- Emphysema
- Bronchitis
- TB
- COPD
6. Gastrointestinal
7. Genitourinary
- Bladder or kidney problems
8. Integumentary
9. Neurological
- Stroke
- Multiple sclerosis
10. Musculoskeletal
11. Hematologic/lymphatic
12. Allergic/Immunologic
13. Psychiatric
- Mental and/or emotional factors
14. Endocrine
A teaching institution might consider these sub categories:
1. Eyes
- Sudden loss or change in vision
- Burning or itching; excessive tearing
- Redness
- Discharge
- Swelling of lid or growth
2. Constitutional
- Fever
- Weight loss or weight gain
- Night sweats
3. Ears, nose, mouth and throat
- Sinus pressure/congession
- Hearing loss
- Dry mouth
- Nose bleeds
4. Cardiovascular
- Chest pain
- Shortness of breath
- Exercise intolerance
- Dependent ankle swelling
5. Respiratory
- Cough sputum, blood
- Wheezing
- Shortness of breath
6. Gastrointestinal
- Nausea/vomiting
- Diarrhea
- Abdominal pain
- Bloody stolls
7. Genitourinary
- Incontinence
- Blood in urine
- Pain with urination
- Difficulty emptying
8. Integumentary
- Rash non/pruritic
- Excessive dryness
- Discoloration
- Bumps or nodules
9. Neurological
- Headache
- Loss of balance
- Weakness
10. Musculoskeletal
- Arthritis
- Pain or swelling
- Loss of range of motion
11. Hematologic/lymphatic
- Increased frequency of infections
- Non-healing wounds
- Excessive bleeding
- Excessive clottings
12. Allergic/Immunologic
- Allergies to new medicines/foods/clothing
- Hay fever
13. Psychiatric
- Depression
- Anxiety
- Difficulty sleeping
14. Endocrine
- Increased urination or thirst
- Palpitations
- Anxiety
- Weight loss or weight gain
Coding Tips
- To save time, offices can mail, email or fax a systems questionnaire to the patient for completion before the new patient visit.
- You should complete a comprehensive ROS on each new patient.
- For established patients, you may not always need a comprehensive ROS. Doing one may, in fact, inflate the level of exam that is billed. Document only what is medically necessary to review for today’s visit see table.
- Any time a patient responds “yes” to a problem with a certain system, make a note about what the patient is doing to care for the problem. For example, if the patient says he or she has asthma, supporting documentation could note that the patient carries an inhaler. If a patient notes an issue with his or her endocrine system, it would be appropriate to mention that a primary care doctor is monitoring him or her for diabetes.
| Systems Reviewed | ROS Needed |
|---|
| 10 or more |
Complete |
| Two to nine |
Extended |
| Only the system in the HPI |
Problem-pertinent |
All Others Negative
To check the box for “all others negative,” you should have individually documented at least 10 organ systems with either positive or pertinent negative responses. For the remaining systems, a notation showing all other systems are negative — and indicating the remaining four systems — is appropriate.
However, you shouldn’t document fewer than 10 systems and then indicate “all others negative” in order to meet the requirement. The same is true with an electronic medial record and its own “all others negative” statement. If a system is marked positive, documentation should include what is being done to care for the specific problem.
Over the course of the next month, try it out for yourself: scrutinize the ROS in your own documentation. For other ROS examples, visit the American Academy of Ophthalmic Executives’ Practice Forms Library.
Next month, YO Info will take a look at the PFSH component of E&M documentation. Future issues will include the chief complaint and elements of the history of the present illness as well as the eye examination.