decisionhealth Newsletters, Coder Pink Sheets - 2005 Issue 11 (November)
Documenting careful history can raise level of new patient E/Ms
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Article Overview
This article discusses documentation of history in ophthalmic evaluation and management services, with emphasis on the history of present illness and how it affects service level selection for new versus established patients. It is written for ophthalmologists and coders who want to understand documentation requirements, history components, and the general relationship between exam, history, and medical decision-making in E/M coding.
Why This Topic Matters
Accurate history documentation can influence whether a visit supports a higher or lower evaluation and management level, which affects coding accuracy and reimbursement.
What You Will Learn
- How the history component fits into evaluation and management services
- What elements are used to document the history of present illness
- Why documentation quality can affect new-patient and established-patient E/M levels
- How ophthalmology visits may be impacted by history documentation
- General distinctions between brief and extensive history documentation
Who Should Read This
- Ophthalmologists
- Medical coders
- Billing staff
- Practice managers
Codes Discussed
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