Learning from “History” – Ophthalmic Professional
Patient history can be essential to coding choices.
This issue’s column deals with history of documentation requirements and some of the confusion surrounding them. The history is an important part of every single patient work-up and directly impacts the possible coding choices and coverage.
It’s important the physician performs some history elements, but other elements require provider confirmation during the visit. The chief complaint determines whether the patient or the insurer is responsible for payment. History of Present Illness (HPI), Review of Systems (ROS), and Past Personal, Family and Social History (PFSH) are factors that determine the level of service. Since we do not know what code will be used at the beginning of an exam, it would be best to take histories with the possibility of an Evaluation and Management (E/M) code 99201-99215 in mind.
This article addresses the following topics:
- Chief Complaint
- History of Present Illness
- Review of Systems
- Past Personal, Social, and Family History (PFSH)
This article was published in Ophthalmic Professional’s Coding column, and written by Corcoran’s Senior Consultant, Paul Larson, COE. To view the entire article in Ophthalmic Professional, click on the link below: