Master history of present illness documentation – Ophthalmology Management

It’s just as important for you to document the history of present illness (HPI) as it is to document the chief complaint. Here are our instructions for how to do that correctly and support reimbursement.

This article answers the following questions:

  • How does the HPI impact the level of service?
  • Who may perform the components of the history?
  • Is use of a scribe permitted?
  • Do the eye codes (920xx) require documentation of the HPI?

This article was published in Ophthalmology Management’s Coding & Reimbursement column, which is written by Corcoran’s Executive Vice-President, Suzanne Corcoran, COE. To view the entire article in Ophthalmology Management, click on the link below:

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