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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 Requires3 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 / ExpandedProblem
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+ = multiple6+= extensive
Amount and Complexity of Data_____
Circle Oneminimallimitedmoderateextensive
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 / LowComplexity / 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 Intermediateophthalmological 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
92014Comprehensive 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, min1 / 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 ______
Applying the Definitions of Current Procedural Terminology (© American Medical Assn.)
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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