Ophthalmology and Optometry Coding Alert

Ensure you have documentation of each system -- or prepare to assign a lower code.

Level-four and level-five office visits are not uncommon in an ophthalmology practice, but if you incorrectly capture the history, exam, and medical decision-making (MDM), you will miss out on the higher level codes you could report.

Background: All documentation requires a chief complaint (CC) (which may be captured as part of the history), history, examination and MDM. The history component of an E/M service is further broken down into three elements: history of the present illness (HPI), review of systems (ROS) and past, family, social history (PFSH). Most often, physicians do not document the ROS element completely although the work in obtaining this information was performed. This may be because pertinent negatives responses were not documented or lack of the "all systems were reviewed and are negative" statement. The resultant level of E/M service may mean selection of a lower level, even though the work was performed. If it is not documented, it cannot be counted in determining the level of E/M code assignment.

Ensure you're properly counting your ophthalmologist's ROS with this primer to guarantee you're not overcoding or undercoding E/M services.

Differentiate ROS Levels

"The review of systems is a subjective account of a patient's current and or past experiences with illnesses and or injuries affecting any of the 14 applicable organ systems," explains Nicole Martin, CPC, manager of the medical practice management section of the Medical Society in New Jersey in Lawrenceville.

You'll need to know the differences between the three ROS levels to determining the proper level of history and therefore, E/M code level:

Problem-pertinent: A problem-pertinent ROS occurs when the ophthalmologist reviews a single system during the encounter, presumably the system directly related to the problem identified in the patient's history of present illness (HPI). For an ophthalmology practice, "pertinent" refers to the eyes.

A problem-pertinent ROS supports a level two new patient E/M service (99202) or a level three established patient E/M service (99213).

Extended: When the physician conducts an extended ROS, he should review a "limited" number of systems. According to Medicare (and most other payers), "limited" should be a total of two to nine systems including the eyes.

An extended ROS can support a level three new patient service (99203) or a level four established patient service (99214).

Although an ophthalmologist primarily treats the eyes, he needs the whole picture as there may be factors that are pertinent to the vision problem.

Complete: When your ophthalmologist reviews 10 or more systems, he achieves a complete ROS. A complete ROS can support a level four or five new patient E/M (CPT 99204 -99205) or a level five established patient visit (99215).

Learn the Systems You Will Be Counting

One of the systems that you'll see your ophthalmologist address during a ROS is, of course, the eyes. Examples of an eye ROS might include the following symptoms, according to Maggie M. Mac, CPC, CEMC, CHC, CMM, ICCE, Director, Best Practices-Network Operations at Mount Sinai Hospital in New York City:

• Eyes (e.g. loss of peripheral vision, dry, watery or irritated eyes, floaters, visual disturbances)
• Endocrine (e.g. diabetes)
• Ears, Nose, Mouth, Throat (e.g. chronic sinusitis)
• Cardivoascular (e.g. hypertension)
• Allergy/Immunologic (e.g. allergies to environment, medications, etc.)
• Neurologic (e.g. headaches, tingling, loss of sensation)
• Skin (e.g. dermatitis, dry skin, scaly skin)
• Psychiatric (e.g. memory loss, depression)
• Respiratory (e.g. asthma, shortness of breath)
• Constitutional (e.g. fever or chills).

Example: A new patient presents with chronic eye irritation and dry eyes. Your ophthalmologist may find it necessary to review all the systems listed above to rule out any underlying cause and to determine if other current medical conditions (such as diabetes or hypertension) and medications can exacerbate the eye symptoms. Performance of a complete ROS is necessary and documentation should include all pertinent positive and negative responses. A notation of "All other systems reviewed and are negative" for the remaining systems is acceptable for most payers. However, check for specific details on documentation of the ROS with your local payer.

"I have found that many physicians document only pertinent clinical findings instead of documenting all of the work performed," notes Mac. "Documentation should always reflect all work performed, including negative findings."

Determine Who Can Record the ROS

The ophthalmologist does not necessarily need to record the ROS himself. "The ROS may be documented by the patient or auxiliary staff as long as the physician/NPP initials and dates patient populated forms and states they reviewed and/or agree with this documentation," Martin says.

Example: "ROS can be done by a physician assistant (PA), nurse practitioner (NP), or a medical assistant (MA)," explains Ruth Borrero, claims analyst at Prohealth Care in Lake Success, N.Y. You may even have the patient fill out an ROS questionnaire, which the doctor reviews and signs.

"It helps our doctors and nurse practitioners to have the patient fill out a questionnaire that addresses their problems when they come to an appointment to make sure that all problems are addressed during their encounter," says Becky Boone, CPC, CUC, certified reimbursement assistant for the University of Missouri Department of Surgery in Columbia. "I encourage this as a good way to make sure that ROS is documented completely."