Documentation of the patient work-up interview often lacks the critical pieces.

The American Medical Association’s 2021 changes to the CPT Evaluation and Management (E/M) codes and guidelines took some of the focus off the documented medical history and exam elements when assigning the level of E/M code selection.

Don’t let your staff interpret this to mean they can omit the history altogether. Accurate charting is as important as ever. In CMS’s Comprehensive Error Rate Testing Report from 2020, the largest source of errors was insufficient documentation (63%). The remaining 37% of the observations in order of most common were lack of medical necessity, incorrect coding, other errors, and no documentation.

Here’s how you can ensure you are sufficiently documenting a patient’s medical history so that you can avoiding errors in your charts.

Chief complaint

Thorough documentation begins with recording the reason for the encounter, or the “chief complaint.” Medicare defines the chief complaint as “... a concise statement describing the symptom, problem, condition, diagnosis, physician recommended return, or other factor that is the reason for the encounter, usually stated in the patient’s words.”¹ In short, it describes why the patient is in your office.

This sets the stage for the physician’s exam and is important in determining who is responsible for reimbursement: medical insurance, vision insurance, or the patient. Ideally, the process of obtaining this information began with the patient’s call to schedule the appointment. Once in the exam lane, a physician or any appropriately trained member of the staff can confirm the reason for the visit and the patient’s concerns by starting with an open-ended question such as, “How can we help you today?”

Determining coverage

Coverage and payment for office visits depend on the purpose of the examination, as well as the ultimate diagnosis. Complaints, symptoms of eye disease or injury, or exams to monitor existing conditions are covered by medical insurance, including Medicare and Medicaid plans.

Routine physical checkups are usually excluded from coverage by Medicare, as well as other third-party payers. These visits are defined as, “Examinations performed for a purpose other than treatment or diagnosis of a specific illness, symptoms, complaint, or injury…”² Exceptions apply for certain statutorily covered screening exams (eg, glaucoma screening).

Additionally, the Medicare benefits manual states, “Routine physical checkups; eyeglasses, contact lenses, and eye examinations for the purpose of prescribing, fitting, or changing eyeglasses; eye refractions by whatever practitioner and for whatever purpose performed; hearing aids and examinations for hearing aids; and immunizations are not covered.”³ Routine eye exams are usually billed to vision plans or to the patient.

When multiple complaints are given

Some patients provide two complaints. Consider the case of a patient scheduled for a glaucoma follow-up visit who asks for new eyeglasses. The request for new eyeglasses sounds routine and refractive, but monitoring glaucoma is not.

According to CMS instructions to Medicare Administrative Contractors,⁴ the complaint related to disease or injury is separate and distinct from the indication for a refraction, and the denial of the refraction has no effect on the payment for the covered eye exam on the same day.

In this case, report the glaucoma diagnosis on the office visit, and the refractive error is the diagnosis for the non-covered refraction.

Importance of a few extra questions

In the patient work-up, the history of present illnesss (HPI) usually follows the chief complaint. Ask the patient to provide some detail about their symptoms or condition: which eye, how severe, how long, etc. Although the level of E/M code is not dependent on how well the HPI is documented, the information can impact coverage of future services and is often needed for claim preparation.

Consider these examples:

1. Chart reads:

• CC: Floaters
• HPI: A 63-year-old new patient presents for DM check. Reports an increase in floaters x 3 days
• Hx: DM x 7 years

What’s missing? Type of diabetes (type I or type II) along with what, if any, diabetic medication the patient is taking. This information is needed to assign an ICD-10 code.

Also, a description of the floaters is missing. Is it a singular floater or a cluster? Any flashes of light? Constant or intermittent? One or both eyes? This provides the doctor with useful information.

2. Chart reads:

• CC: Annual eye exam
• Hx: DM x 20 yrs, well controlled with insulin
• Exam: BCVA 20/400 CC, 2+ NS OU, 1+ PSC OU.
• Dx: NS cataracts OU, PSC OU
• Tx: Schedule surgery, OS

What’s missing? The cataract surgery is not supported without a documented complaint as well as impact on visual function.

3. Chart reads:

• CC: Returns for 6-month glaucoma follow-up as directed
• Hx: Latanoprost prescribed at last visit
• Exam: BCVA 20/400 CC, 2+ NS OU, 1+ PSC OU. IOP 26/28
• Dx: NPOAG, OU. IOP exceeds target
• Tx: Consider SLT

What’s missing? There is no mention of the patient’s understanding of and compliance with the eyedrop use instructions.

Conclusion

Obtaining a chief complaint requires more than a vague question, “Why are you here?” Take time to pay attention to patients as they describe their concerns. The goal is to be concise yet thorough. Anticipating the physician’s next question or next step can be useful.

Finally, the scribes working in the exam lane can augment the chart by adding notes from the patient’s conversation with the doctor. OP

REFERENCES:

1. Center for Medicare and Medicaid Services. HCFA 1997 Documentation Guidelines for Evaluation and Management Services. https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnedwebguide/downloads/97docguidelines.pdf . Accessed Jan. 21, 2022.
2. Social Security Administration. Social Security Act 1861(s)(2)(U). https://www.ssa.gov/OP_Home/ssact/title18/1861.htm . Accessed Jan. 21, 2022.
3. Center for Medicare and Medicaid Services. Medicare Benefits Policy Manual Chapter 16, §90. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c16.pdf . Accessed Jan. 21, 2022.
4. Center for Medicare and Medicaid Services. Transmittal 1690, January 5, 2001. https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R1690B3.pdf . Accessed Jan. 21, 2022.