In ophthalmology, the chief complaint (CC), patient history, and a technician curious enough to ask the correct questions all play a crucial role in guiding the physician through the diagnostic process. In fact, a study by the Journal of Current Ophthalmology reported, “one experienced senior attending physician was able to correctly diagnose a problem 88% of the time based on chief complaint and history, demonstrating the remarkable diagnostic value of patient history in clinical practice.”¹

Keeping that in mind, let’s discuss the key components of a patient history, how the new E/M (evaluation and management) guidelines give latitude for patient workups, and ideas on how to use your electronic health record (EHR) to create increased efficiency.

The three key components

A patient history typically includes three key components: the CC, which is supported by a relevant history of present illness (HPI), a thorough medical history, and a Review of Systems (ROS). Palmetto, a Medicare Administrative Contractor (MAC), states a CC “is a concise statement describing the symptom, problem, condition, diagnosis, physician recommended return or other factor that is the reason for the patient encounter. A CC is required for all levels of service.”² The CC is usually stated in the patient’s own words.³

The patient’s medical history typically includes any medications, both systemic and ocular, past surgeries, and family and social history, as well as any allergies. Obtaining a thorough history for the initial patient visit is essential, but may not be needed at every patient encounter.

The ROS is an inventory of other organ system symptoms the patient is experiencing, such as hearing loss, headache, cough, etc.

Two choices for office visits?

In eye care, we can choose from two different categories of codes for the office visit in which the provider is either evaluating or managing a patient: E/M (99202-99215) and eye codes (9200X/9201X). The E/M codes were simplified in 2021, allowing a more streamlined process (see “E/M code changes give latitude,” P. 25.) This update gives physicians flexibility and the opportunity to establish “medically appropriate”⁴ history and exam protocols to help streamline different encounter types.

Fortunately, many of the eye code requirements overlap with the “medically appropriate” history and exam elements for E/M code selection. (For more insights into code selection, see “Evaluation and management coding in 2021,” Ophthalmic Professional, January/February 2021 at bit.ly/OP2101coding .) The 2023 Current Procedural Terminology (CPT) Ophthalmological Services Guidelines for the eye codes require a “history” and “general medical observation” at both the intermediate and comprehensive eye code levels.⁵ As discussed above, a CC is necessary to establish medical necessity for all exams. But again, “history” and “general medical observation” are somewhat vague. If the key components are documented, such as patient medications, surgeries, ROS, etc., the documentation should support both an E/M and eye code, expanding the opportunity to choose the code with the highest reimbursement for the documentation present (think 92014 vs. 99213).

Update or establish protocols

The update to the E/M codes was meant to simplify the documentation process and lessen the burden on clinicians. Therefore, now is a great time for eyecare practices to update or establish workup protocols. Typically, follow-up encounters with specific intervals have expectations for what is obtained during the exam and can differ based on subspecialty. For example, a glaucoma specialist may see a stable primary open angle glaucoma (POAG) patient once a quarter to check their pressure, whereas a comprehensive ophthalmologist may see a stable diabetic patient once a year. It’s important for practices to find these patterns and implement efficiencies to help clinical staff obtain what is “medically appropriate” for the physician so they do not have to sift through unrelated or unnecessary documentation, commonly known as “note bloat.”

The following table shows examples of a unique history and exam workup protocols for various encounter types, including important questions to ask the patient regarding specific encounter types:

Tap into EHR efficiencies

Many EHRs have the option to customize templates based on specific exam types, subspecialties, or even a specific physician. Developing different templates may ease the clinical burden and help technicians obtain only the information clinically relevant to that exam. For example, many EHRs can highlight different elements of the patient exam to alert the technician to what must be completed. Highlighted elements can be different depending on the exam type. Consultations and annual exams may have CC, history, ROS, visual acuity (VA), intraocular pressure (IOP), pupils, extraocular motility (EOMs), and confrontation visual fields (CVFs) highlighted to ensure a thorough exam is completed. Conversely, a brief IOP check may only have CC, ophthalmic medical history, VA, and IOP highlighted, as these are the medically appropriate elements for this encounter type. Also, keep in mind that not all EHR HPI prompts are pertinent to the CC, such as asking a cataract patient about pain.

Consider meeting with your subspecialty teams or individual providers to understand how many exam templates are needed and which exam types overlap to minimize the number of customized templates needed.

Avoid information “cloning”

Although the EHR can be a great tool for templates, it can also cause significant trouble with “cloning” or “copy forward” features, as well as the ability to mark everything “normal” prior to starting the exam. As discussed, the information the technician gathers within the CC, history, and exam contributes significantly to the diagnostic outcome for the patient. If the chart is marked “normal” for everything and accidentally left “normal” when the CVFs show a superior defect, the physician could go down a different diagnostic rabbit hole than what is truly indicated.

This risk applies to the chief complaint as well. The information could be misleading if copied forward from another encounter and not updated. For example: A patient being seen for a corneal abrasion follow-up is expected to have a healed epithelium and reduced symptoms. The cloned CC, carried forward from the previous exam and not updated for this encounter, erroneously states “significant pain” and “blurry vision.” However, the vision is back to baseline at 20/20. Something is not adding up. It may seem minor, but now the physician is potentially spending more time examining the patient and possibly performing other diagnostic tests to determine the cause of the pain and subjective blurry vision because he thinks the patient is still having trouble.

As we know, time is valuable, so to ensure the physician is as efficient as possible, the CC and patient history must be accurate to help streamline the exam.

Going forward

The significance of complete and accurate patient histories and examinations in patient care cannot be emphasized enough. Thanks to the revised E/M guidelines of 2021, we can be targeted and focused in obtaining these essential details.

By dedicating some effort to customization, our EHR systems can support us in generating informative chart notes that enhance our physicians’ ability to deliver accurate and efficient patient care. Let’s use these opportunities to work smarter and enhance the quality of patient care. OP

REFERENCES

1. Wang, WY, Asanad S, Asanad K, Karanjia R, Sadun AA. Value of medical history in ophthalmology: A study of diagnostic accuracy J Curr Ophthalmol. 2018 Sep 27;30(4):359-364. doi: 10.1016/j.joco.2018.09.001. PMID: 30555971; PMCID: PMC6277212.
2. E/M Weekly Tip: Chief Complaint. Palmetto GBA. https://www.palmettogba.com/palmetto/jmb.nsf/DIDC/8UYH6H3481~ Evaluation%20and%20Management%20(EM)~Tips#:~:text=A%20chief%20complaint%20(CC)%20is,for%20all%20levels%20of%20service . Accessed September 15, 2023.
3. Evaluation and Management Services Guide. Medicare Learning Network. https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/eval-mgmt-serv-guide-icn006764.pdf . Accessed September 15, 2023.
4. CPT Evaluation and Management (E/M) Code and Guideline Changes 2023.American Medical Association. https://www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf . Accessed September 15, 2023.
5. CPT 2023. American Medical Association.
6. Evaluation and Management (E/M) Office Visits – 2021. American Medical Association. https://www.ama-assn.org/system/files/2020-04/e-m-office-visit-changes.pdf  Accessed September 15, 2023.

BRITTNEY IRWIN, COT, CPC-A, CEP joined BSM as a consultant in 2022 and is located in Durango, Colo. Prior to joining BSM, she spent 10 years working in ophthalmology, most recently as the clinical director of a multi-specialty group.

Laurie K. Brown, MBA, COMT, COE, CPC, CPMA, CPSS, LSSYB is a senior consultant with BSM Consulting in Tucson, AZ. She has experience in the ophthalmic industry holding managerial, clinical, and surgical roles for more than 30 years.