Anyone involved with direct patient care understands that an examination can only begin once the purpose for the patient visit is  known. The patient history, especially the chief complaint, drives the entire process. This article will discuss the key elements for taking a patient history with emphasis on the relationship between the history and efficient, cost-saving operations.

Chief Complaint
The patient history begins with the chief complaint. It should detail the primary reason(s) the patient scheduled the examination. Ideally, it should be recorded in the patient's own words. The chief complaint also suggests what tests you'll need to perform and the possible CPT code to use for the encounter.

Reimbursement and efficiency are intimately linked to the chief complaint. Without a chief complaint, there can be no legitimate claim made for reimbursement. From an efficiency perspective, if the technician records the history, the chief complaint should guide the technician component of the examination. If the tech omits key technician examination elements, inefficiency creeps into the system. The physician may return the patient to the technician for additional tests, such as confrontation visual fields or extraocular motility, that should have been completed the first time around. As a result, everyone wastes time and inconveniences the patient.

Some patients may be poor historians or honestly unable to verbalize a chief complaint, and eliciting a patient complaint is sometimes more art than science. When queried, some patients might say, "I'm just here for a checkup." or, "I want to get new glasses." Either of these two responses would disqualify reimbursement by some payers (e.g. Medicare), since "routine" services may not be reimbursable. If eliciting a chief complaint is difficult, try these strategies:

1. Review previous chart notes and ask questions about continuing problems, such as dry eyes or chronic conditions such as diabetes or cataracts.

2. Perform a few examination elements, observe the results, and then try again to determine a complaint. For instance, noting that a patient's reading vision has worsened since the last visit, and then sharing this with him might result in "blurry near vision" as the chief complaint.

3. As a last resort, explain to the patient that in absence of a chief complaint she may have to pay for the visit.

An exception to the above concerns patients who are returning for evaluation of chronic conditions such as glaucoma or macular degeneration. Conditions such as these can be reason enough for a visit even in the absence of specific patient complaints relating to them.
Choosing the Code
Ophthalmology is in the unique position of having two separate coding options. The type of history required is dictated by which option is chosen. When documentation and medical necessity are appropriate for either set of codes, the ophthalmology codes typically pay better, especially for established patients. In my experience, history-taking is much less burdensome when using ophthalmology codes (See "Ophthalmology vs. E/M Codes"). With the "eye codes," less burden translates into more efficiency, less documentation, oftentimes less compliance scrutiny and better reimbursement.

Ophthalmology vs. E/ M Codes
Ophthalmology Codes (92xxx): The description for the history-taking element discussed in the American Medical Association's Current Procedural Terminology (CPT) 2004 requires only that eye code documentation include a history. What type of history is not defined. Thus, it's left up to the judgment of those using the codes, or the guidance from the local Medicare carrier, to determine what type of history is appropriate in each situation. It may be appropriate to record only a chief complaint.
Evaluation and Management (E/M) Codes (99xxx): History-taking to support the use of E/M codes is an entirely different issue. The complexity of the various E/M codes is typically referenced in terms of levels ranging from 1 to 5, with level 5 being the most complex. The history-taking requirements vary, as do the levels. However, all levels have the same four basic history-taking components in common: Chief Complaint; History of Present Illness (HPI); Review of Systems (ROS) and; Past, Family and/or Social History (PFSH).

Coding Choice Determines Detail

A goal of efficient and cost-effective history taking is to anticipate the level of service. By that, the history-taker should have a fairly good understanding not only of the type of code the physician may choose but also its level. Though coding is beyond the scope of this article, note that history-taking documentation requirements become more complex as the level of service increases. Other than the chief complaint, each of the other three Evaluation and Management history-taking components (see sidebar previous page) have specific elements or "bullets." The type and number of bullets required to support the level of service increase as the level increases. History-takers should have a thorough understanding of the requirements for each code. Such an understanding is necessary both from an efficiency and reimbursement perspective. For instance, if the physician has to take time supplementing the technician history, the physician is slowed down, the patient is inconvenienced and patient throughput suffers. Additionally, it's possible that the encounter will have to be coded at a lower level, and thus reimbursed at a lesser rate.

E/M History-taking Components
History of Present Illness (HPI). A good rule of thumb is to try to elicit at least four HPI bullets or the status of three or more chronic or inactive conditions. (See example above).
• Associated signs and symptoms (halos, pain, tearing, discharge, redness, foreign-body sensation, floaters, dizziness)
• Context (after medication, while driving, reading)
• Duration (date of onset)
• Location (eye or adnexa)
• Quality (blurry, foggy vision, double vision)
• Modifying Factors (medication/therapy improvement, no improvement or worsened, heat versus cold, opening or shutting eyelids)
• Severity (usually degrees of pain or loss of sight)
• Timing (a.m., p.m., mealtime, arising from prone position or lying down).

Review of Systems (ROS). These E/M history components are perhaps the most time-consuming. Many practices use pre-printed forms that can be filled out by patients. Some practices actually mail these forms to all new patients in advance of the examination date. Elements comprising the ROS range from allergic/immunologic to cardiovascular to musculoskeletal and respiratory.
When documenting the ROS, seek to identify signs and/or symptoms that the patient is experiencing or has experienced. A review of 10 or more systems will provide proper documentation to qualify any level E/M code. Lesser systems are required for lower-level services.

Interpreting History of Present Illness
Here is an example of how to properly interpret some of the HPI bullets. Mrs. Smith presents with the following HPI: "I have a red right eye that began two days ago. It's not painful, but my eyelids have been stuck together in the mornings the past two days.
• Associated signs and Symptoms: Red eye, eyelids stuck together
• Duration: Two days ago
• Location: Right eye
• Severity: Not painful
• Timing: In the mornings
Thus, this particular history elicited five of the eight bullets. This component would qualify the visit for any E/M code the physician may choose.
Past, Family and/or Social History. The patient may consider this information to be interrelated, but he may reveal key information under one set of questions that he did not think of under another:
• Past History (past illnesses, operations, injuries, treatments)
• Family History (family medical events, including diseases, which may be hereditary or place the patient at risk)
• Social History (an age-appropriate review of past and current activities like smoking, drinking).
Documenting all three of the above will qualify an examination for any level, but different documentation requirements exist for different levels and for new versus established patients. Consultation codes require the same history-taking components as new patient E/M codes at the same level (e.g. 99243 requires the same history as the level 3 new patient code 99203.)

A variety of resources are available to hone history-taking skills. Convenient resources are the physicians and senior-level technicians in your practice. Coding books, such as the CPT book referenced above, are also useful. History-taking courses are typically offered at the JCAHPO Annual Continuing Education Program and the Clinical and Surgical Staff Program sponsored by the American Society of Ophthalmic Administrators in conjunction with the ASCRS/ASOA annual meeting.  

Mr. Woodworth is chief operations officer at the Kentucky Eye Institute in Lexington and president-elect of the Joint Commission on Allied Health Personnel in Ophthalmology. Contact him at