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Billing Documentation Training
For the Medical Eye Services
Provider
Why document ALL Services
Provided?
MUST REMEMBER CMS’s (Medicare)
Rule…
 If it isn’t documented, it didn’t happen

If it didn’t happen, you cannot bill
A Crime!

Coding for services not provided
is a CRIME

Fraud: Billing for services never rendered
Documentation Is Coded

Proper documentation of services
provided results in the ability to assign
the proper procedure and diagnosis
codes
Medical Eye Services Covered

Billable to medical insurance
Office Visits
 Diagnostic Testing (report of findings must
be in patients chart)
 Surgical Procedures (surgical report must
be in patients chart)
 Office Procedures (minor surgical report
must be in chart)
 Refraction (seldom covered)

E/M Codes
(Evaluation and Management)

Used to code Office Visits for medical
eye services
Patient Status Factor
New patient
 Established patient

New Patient

Has not received any professional
service in last 3 years from:
The same Provider
 From another Provider of the exact same
Specialty and subspecialty and in same
group


New patients more labor intensive for
Provider and staff
Established Patient

Has received professional services in last
3 years from:
The same Provider or
 Another Provider of exact same specialty and
subspecialty in same group


Medical record available with current,
relevant information
E/M Levels Are Divided Based On
Key Components (KC)
 Contributory Factors (CF)
 Every encounter contains varying
amount of KC and CF

Key Components
History
 Examination
 Medical decision making

Encounters

More of each component/factor


Higher level of service
Less of each component/factor

Lower level of service
Four Elements of a History
Chief Complaint (CC)
 History of Present Illness (HPI)
 Review of Systems (ROS)
 Past, Family, and/or Social History (PFSH)

Chief Complaint (CC)—Subjective

Reason for encounter
Patient’s current complaint
 Usually presented in patient’s own words

Documented in medical record for each
encounter
 Required for all levels of service
 May not be stated as “CC” but is inferred
from documentation

History of Present Illness (HPI)—
Subjective

Chronological description of the
development of patients current illness from
the first signs and/or symptoms or from the
previous encounter to present.

Alternatively, you can record status of at
least 3 chronic conditions or inactive
condition

Ie:
controlled, worsening, improving
History of Present Illness (HPI)—
Subjective

Patient describes HPI

If patient cannot answer for themselves,
a parent, guardian, or other may provide

Provider must document
8 Elements of HPI
1.Location-(Which eye or eye segment
AND condition-Eye Pain, Dry Eye or
Diagnosis-Glaucoma, Cataract)
 2.Quality-(Ache, Irritation)
 3.Severity-(Severity of Condition or
Diagnosis)
 4.Duration-(Started 3 days ago)

8 Elements of HPI (Con’t.)
5.Timing-(Continuous, comes & goes)
 6. Context-(Cause)
 7. Modifying Factors- Does anything
make it better or worse (Cold compress
helps)
 8. Associated Signs or Symptoms
(Blurred Vision)

Provider and Patient Dialogue
Examples

Example 1. Condition easily described by Patient:
Bilateral floaters (location) Affect Vision (quality)
Started one year ago (Duration) Occurs daily (timing)

Example 2. Diagnosis not easily described by patient:
Bilateral Glaucoma (location) Increased Optic nerve
head (severity) Diagnosed six months (duration)
continuous timing) .”
NOTE: Both examples show 4 elements of HPI
Review of Systems (ROS)—Subjective

Record the patients positive and
negative findings in each body system as
it relates to the chief complaint
Extent of ROS Depends on CC

Example: Do not usually review
musculoskeletal system for CC of eye pain
 Example: A patient who has sustained trauma
from an auto accident and cannot discern
difference
 Medical necessity for the number of OSs
inventoried must be implied or documented
Systems in ROS
Constitutional—General, Fever, Weight
Loss or Gain
 Eyes—Organ System (OS)
 Ears, Nose, Mouth, Throat (OS)
 Cardiovascular (OS)

(Cont’d…)
Systems in ROS
(…Cont’d)
Respiratory (OS)
 Gastrointestinal (OS)
 Genitourinary (OS)
 Musculoskeletal (OS)
 Integumentary (OS)

(Cont’d…)
Systems of ROS
(…Cont’d)
Neurologic (Neurological) (OS)
 Psychiatric (OS)
 Endocrine (OS)
 Hematologic/Lymphatic (OS)
 Allergic/Immunologic (OS)

Past, Family, and/or Social History
(PFSH)

Past and Social History contains relevant
information about past:






Major illnesses/injuries
Operations
Hospitalizations
Allergies
Immunizations
Dietary status
(Cont’d…)
Past and Social History
(…Cont’d)

Social history contains relevant
information about:
Sexual history
 Other relevant social factors
(Example: Employment)

Past-present medications
 Social tobacco/alcohol use

Family History

Health status of family members:
Parents
 Siblings
 Children


Family history items related to CC
History Levels
Four history levels:
1. Problem focused
2. Expanded problem focused
3. Detailed
4. Comprehensive
Summary of Elements Required for
Each Level of History

Must have 2/3 for established patient
 Must have all 3 (HPI, ROS & PFSH) for new
patient
Examination—Objective (Handson)

Four levels of examination:
Problem Focused
 Expanded Problem Focused
 Detailed
 Comprehensive

Elements of Medical Eye
Examination
Test visual acuity (does not include
determination of refractive error)
 Gross Visual field testing by
confrontation
 Test ocular motility including primary
gaze alignment
 Inspection of bulbar and palpebral
conjunctivae

Elements of Medical Eye
Examination (Con’t.)
Ocular adnexae including lids, lacrimal
glands and drainage, orbits &
preauricular lymph nodes
 Pupils and irises including shape, direct
and consensual reaction, size, and
morphology
 Slit lamp examination of the corneas
including epithelium, stroma,
endothelium, and tear film

Elements of Medical Eye
Examination (Con’t.)
Slit lamp examination of the anterior
chambers including depth, cells and flare
 Slit lamp examination of the lenses
including clarity, anterior and posterior
capsule, cortex and nucleus
 Measurement of the intraocular pressure

Elements of Medical Eye
Examination (Con’t.)
(Through Dilated Pupils)
 Optic disc size, C/D ratio, appearance
and nerve fiber layer
 Posterior segments including retina and
vessels
Remember

Extent of examination depends on needs
of patient and expert judgment of
provider
Medical Decision Making
Complexity (MDM)

Level of MDM is significantly different for:
Patient A uveitis
 Patient B retinal detachment

Three Elements of Medical Decision
Making (MDM)
1.

Number of diagnoses or management
options
Minimal, limited, moderate, or extensive
(Cont’d…)
Elements of MDM
(…Cont’d)
2.

Amount and/or complexity of data to be
reviewed by Provider
Minimal, limited, moderate, or extensive
(Cont’d…)
Elements of MDM
(…Cont’d)
3.

Risk of complications or death
(morbidity or mortality)
Minimal, low, moderate, or high
Four Levels of MDM Complexity
Straightforward
 Low
 Moderate
 High

Management Options

Based on number of possible diagnoses
(definitive or differential) and/or various
ways condition can be treated
Amount or Complexity of Data
Remember, If you think it, ink it!
 If a diagnostic service (test or procedure)
is ordered, planned, scheduled or
performed at the time of the encounter,
the type of service should be
documented
 The review of lad, radiology and/or other
diagnostic test should be documented. A
simple notation such as “WBC elevated”

Amount or Complexity of Data




A decision to obtain old records or decision to obtain
additional history from the family or caretaker should
documented
Relevant finding from review of old records or from
history from family or care taker should be
documented
The results or discussion of labs, radiology or other
diagnostic test should be documented
The direct visualization and independent interpretation
of an image, tracing or specimen previously or
subsequently interpreted by another physician should
be documented.
Risks

Risks of morbidity (poor outcome),
complications, or mortality (death)
with problem and/or treatment
(Cont’d…)
Risks
Other diseases or factors that
affect risks
 Diabetes
 Extreme age

(Cont’d…)
Patient Risk Levels
Summary of Elements Required for
Each Level of MDM
Only 2 of 3 categories must meet or exceed the element
stated to assign the level
Summary of Codes & Levels
Summary of Documentation Needs





If its not documented, it didn’t happen
Must always have a chief complaint on the progress
note
Gather as much detail as possible of CC (8 elements)
Notate, the PFSH from earlier dos was reviewed and
initial
More of each component/factor


Less of each component/factor


Higher level of service
Lower level of service
Complete a report of any procedure or diagnostic test
Resources

http://www.cms.gov/Outreach-andEducation/Medicare-Learning-NetworkMLN/MLNProducts/Downloads/eval_mg
mt_serv_guide-ICN006764.pdf