Grading the Patient Encounter, Case # ______

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Grading the Patient Encounter, Case # ______DOS ______

Applying the Documentation Guidelines to Patient Records

Done

Patient’s Personal Data ______Complete ______Incomplete

Date of Previous Exam ______New? ______Established?

Case History

Chief Complaint ______Medical? ______Refractive? _____Either?

History of Present Illness

Location ______

Quality ______

Severity ______

Duration ______

Timing ______

Context ______

Modifying Factors ______

Associated Signs & Symptoms ______

____Brief=1-3 elements ______Extended=4-8 elements

Review of Systems

Constitutional ______

Eyes ______

Ears, Nose, Mouth & Throat ______

Cardiovascular ______

Respiratory ______

Gastrointestinal ______

Genitourinary ______

Musculoskeletal ______

Integumentary ______

Neurological ______

Psychiatric ______

Endocrine ______

Hematologic/Lymphatic ______

Allergic/Immunologic ______

____ Problem Pertinent=1 system ____Extended= 2-9 systems ____Complete = 10-14 systems

Past, Family & Social History

Patient’s Past History ______

Family History ______

Social/Occupational History ______

____Problem Pertinent=1 question ____Complete=Est. Pt, 2 areas; New Pt, 3 areas

Grading Requires
3 of 3 / Problem
Focused / Expanded Problem Focused / Detailed / Comprehensive
H.P.I / Brief / Brief / Extended / Extended
R.O.S. / N/A / Prob. Pertinent / Extended / Complete
P.F.S.H / N/A / N/A / Problem Pertinent / Complete

Case History = ______

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Physical Examination:

Visual Acuity _____

Visual Fields _____

Ocular Adnexa

(lids, lac.glands, lac.drainage, orbits, nodes) _____

Pupils and Irises _____

Motility/versions _____

Corneas _____

Anterior Chambers (depth,angles,cells,flare) _____

Lenses (clarity, capsules, cortex, nucleus) _____

Bulbar & Palpebral Conjunctiva _____

Intraocular Pressures _____

Ophthalmoscopy (dilated)

Discs _____

Posterior Segments _____

Brief Assessment of Mental Status

Orientation to time/place/person _____

Patient’s mood & affect _____

Problem Focused / Expanded
Problem
Focused / Detailed / Comprehensive
Ophthalmic Elements and/or Mental Status Elements / 1-5 / 6-8 / >9 / All ophthalmic, both mental elements

Physical Examination = ______

Medical Decision Making

Number of Diagnoses _____

Number of Management Options _____

Total _____

Circle One 1+=minimal 2-3+=limited 4-5+ = multiple 6+= extensive

Amount and Complexity of Data _____

Circle One minimal limited moderate extensive

Risk of Complications/Morbidity/Mortality in Rx, Dx, Management

Circle One

Minimal = One self limited or minor problem

Low = Two or more self limited or minor illnesses; One stable or chronic illness;

One acute illness or injury; Uncomplicated injury or illness.

Moderate = One chronic illness with mild complication(s); Two stable chronic

Illnesses; An undiagnosed new problem (uncertain prognosis); Acute illness

With systemic symptoms; Acute complicated injury

High = One or more chronic illness with severe complications, Acute or

Chronic illnesses or injuries posing a threat to life, An abrupt change in

Neurological status

Requires 2 of 3 / Straightforward / Low
Complexity / Moderate Complexity / High
Complexity
Dx/Mgt Options / Minimal / Limited / Multiple / Extensive
Amount/Complexity / Minimal / Limited / Moderate / Extensive
Risk / Minimal / Low / Moderate / High

Medical Decision Making = ______

Your office chose: The record supports:

Office visit ______Office visit ______or______

Procedures ______Procedures ______

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Codes for Eye Care Office Visits

Office Visit Choices for Doctor Seeing New Patient

New Patient= Not received services from any doctor of the same specialty

in your practice (or group) in past three years

General Ophthalmological Services, New Patient

92002 Intermediate ophthalmological service, new patient

92004 Comprehensive ophthalmological service, new patient, one or more visits

Evaluation and Management Codes, New Patient

New Patient Requires 3 of 3 Criteria (Excluding Time)

Level / Code / History / Physical Exam / Med. Decision / Time, min.
1 / 99201 / Problem focused / Problem focused / Straightforward / 10
2 / 99202 / Expanded problem focused / Expanded problem focused / Straightforward / 20
3 / 99203 / Detailed / Detailed / Low Complexity / 30
4 / 99204 / Comprehensive / Comprehensive / Mod Complexity / 45
5 / 99205 / Comprehensive / Comprehensive / High Complexity / 60

Office Visit Choices for Doctor Seeing Established Patient

Established Patient=Has received services from doctor of same specialty

in your clinic (or group) during past three years

General Ophthalmological Services, Established Patient

92012 Intermediate ophthalmological service, established patient

92014 Comprehensive ophthalmological service, established patient, one or more visits

Evaluation and Management Codes, Established Patient

Established Patient Requires 2 of 3 Criteria (Excluding Time)

Level / Code / History / Physical Exam / Medical Decision / Time, min
1 / 99211 / Nurse or doctor supervised service / 5
2 / 99212 / Problem focused / Problem focused / Straightforward / 10
3 / 99213 / Expanded problem focused / Expanded problem focused / Low Complexity / 15
4 / 99214 / Detailed / Detailed / Mod Complexity / 25
5 / 99215 / Comprehensive / Comprehensive / High Complexity / 40

Important Note: All Codes on this page are from Current Procedural Terminology© American Medical Association, coding guidelines are from Health Care Financing Administration’s Documentation Guidelines.

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Grading the Patient Encounter, Case # ______DOS ______

to Patient Records for General Ophthalmological Services

Patient’s Personal Data ______Complete ______Incomplete

Date of Previous Exam ______New? ______Established?

(Longer than 3 years ago = New; Less than 3 years = established)

Chief Complaint ______Medical? ______Refractive?

Intermediate Ophthalmological Services Requirements (92002/92012)

New or previously existing problem ______Yes* ______No

Complicated by new problem ______Yes* ______No

History ______Yes* ______No

General Medical Observation ______Yes* ______No

External Ocular/Adnexal Examination ______Yes* ______No

Other Diagnostic Procedures As Indicated ______Yes* ______No

Initiation (or continuation) of Diagnostic and Treatment Program ______Yes* ______No

Note: All areas with asterisk (*) must be checked in order to code 92002 or 92012

Coding Choice _____ 92002

_____ 92012

_____ Neither

Comprehensive Ophthalmological Services Requirements (92004/92014)

General evaluation of the complete visual system ______Yes* ______No

History ______Yes* ______No

General Medical Observation ______Yes* ______No

External Examination ______Yes* ______No

Ophthalmoscopic Examination (with or without mydriasis/cycloplegia) ______Yes* ______No

Gross Visual Fields ______Yes* ______No

Basic Sensorimotor Examination ______Yes* ______No

Initiation (or continuation) of Diagnostic and Treatment Program ______Yes* ______No

Note: All areas with asterisk (*) must be checked in order to code 92004 or 92014

Coding Choice _____ 92004

_____ 92014

_____ Neither

If record fails to support choice of either intermediate or comprehensive ophthalmological service the visit must be coded as a 99000, evaluation and management service.

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