1997 Documentation Guidelines permit highest level of physical exam coding

Issue: November 1998

ByCharles B. Brownlow, OD

Last month's column discussed the 1997 Medicare Documentation Guidelines and their importance for optometrists and ophthalmologists. The guidelines are not yet mandatory and will be replaced by a new set of guidelines in 1999, but they are still used during the audit process. In my opinion, they are the best guidelines to use for structuring your medical records and for choosing Evaluation and Management office visit codes.

Medicare audits will continue through 1998 and into 1999. Medicare's goal in the audits is to find and prosecute any providers guilty of fraud and abuse and to find and collect any payments that have been made in error. The provider's goal in Medicare audits is to keep any payments collected from Medicare. To do that, providers' records must demonstrate satisfactory compliance with either the 1994 or 1997 versions of the Documentation Guidelines.

Supported by medical records

All visits and procedures reported using Current Procedural Terminology (CPT) codes must be supported by medical records showing that each service matches its CPT definition. I recommend that eye doctors keep their records in compliance with the 1997 Documentation Guidelines, as that version is more objective and more user friendly and provides advantages over the 1994 guidelines.

Last month, I described the guidelines for documentation of the case history, including the importance of recording the patient's chief complaint, the history of present illness, the review of systems and the past, family and social history. The column concluded with a description of the method for "grading" the case history as problem-focused, expanded problem-focused, detailed or comprehensive.

This month, we will discuss the second section of the medical record, the Physical Examination. It is important to note that the Physical Examination section of the 1997 Documentation Guidelines reflects the greatest changes from previous years. The 1997 guidelines favor eye care by permitting single system providers, such as optometrists and ophthalmologists, to code to the highest level of physical examination: comprehensive. Previous guidelines required providing a complete multisystem examination to code at the highest levels of physical examination.

Classifying the exam

The Physical Examination section of the medical record contains all the data from the testing that you elect to perform with the patient at each encounter. Just like the case history, the Physical Examination may be classified as problem focused, expanded problem focused, detailed or comprehensive. The choice is made by counting the number of elements included in the examination. Naturally, when more tests are done and more data are recorded, a higher level of physical examination is chosen.

The list of possible elements includes 12 ophthalmic elements:

visual acuity
visual fields
adnexae
versions and motility
pupils and irises
slit lamp examination of cornea
slit lamp examination of the anterior chamber
slit lamp examination of the iris
slit lamp examination of the lens
tonometry
dilated examination of discs
dilated examination of the posterior retina

The record of the physical examination may also include two psychiatric elements:

the patient's orientation to time, place and person
the patient's mood and affect

Upon completion of the physical examination, it is a simple matter of counting the number of elements performed and recorded - ophthalmic and psychiatric - and choosing the level of examination.

Choice of coding

A review of the 12 ophthalmic elements will make it clear that both optometrists and ophthalmologists often perform all elements necessary to permit coding the physical examination at any of the four levels. If the record includes documentation of the tests performed and the results of each test, the provider's choice of coding will be easily supported during an audit.

As we discussed last month in case history, audits are no problem when the record includes the proper documentation and when you have chosen the CPT codes based upon that documentation.

Next month, I will cover the third section of the medical record, Medical Decision-Making. After that, you should be prepared to create medical records that will support your choice of office visits, and you will be able to welcome audits in your office.