Review of Medical History

Whether you are billing an ophthalmologic examination code or an evaluation and management code, every office visit on an established patient requires that the medical history be reviewed and updated by the attending physician.  Without evidence that you provided this care, an auditor can either downcode your office visit or deny reimbursement all together. 

In wellness care, the history elements often do not change, making it difficult to prove that they were reviewed and updated unless you specifically state you did.  The best way to accomplish this is to add a statement to your established visit templates that states you in fact reviewed and updated the history elements.  It is advisable that the attending physician, not a staff member, initial that statement.  A good example of the wording could be:

I personally reviewed and updated the patient history elements.  JWD

Without this specific documentation, you leave yourself open to the opinion of the auditor.  It is far better to make a few more keystrokes to properly document the good care you are delivering.


Joe DeLoach, OD, FAAO                                                                                                                                                                               Optometric Business Solutions