Jill J Luebbert, CPOT, ABOC
Luebbert Consulting & Training
99000’s 92000’s Luebbert Consulting & Training
How you document determines the billing level Luebbert Consulting & Training
Pretest Chairside documentation Luebbert Consulting & Training
It never happened Luebbert Consulting & Training Xxxxxxxx Xxxxxxxxxxx xxxxxxxxxxxx
SOAPSOAP Luebbert Consulting & Training
S = Subjective Data NOW PFSH and ROS O = Objective NOW Physical Examination A = Assessment Remains Assessment P = Plan NOW Medical Decision Making & Management Luebbert Consulting & Training
Subjective Data HPI ◦ History of Present Illness PFSH ◦ Past, Family, and Social History Luebbert Consulting & Training
‘What brings you here today?’ Luebbert Consulting & Training
Determines what happens next Is the chief complaint medically oriented? Luebbert Consulting & Training Refractive Medical
Vision cloudy Feel itchy Teary Vision fluctuates Shadows Headaches Red Luebbert Consulting & Training
NOW…………. CODES Luebbert Consulting & Training
DOCUMENT!!!!!!!!! Luebbert Consulting & Training
Location (where) Quality (sharp, dull, hazy) Severity (mild, severe, bothersome) Duration (constant, off & on) Timing (mornings, mid-day) Context (driving, reading) Modifying Factors (bright light, close eyes) Associated Signs & Symptoms(itch, headache) Luebbert Consulting & Training
If you investigate and document 1 – 3 items ◦ Brief If you investigate and document 4+ items ◦ Extended Luebbert Consulting & Training Location (where) Quality (sharp, dull, hazy) Severity (mild, severe, bothersome) Duration Timing Context Modifying Factors Associated Signs & Symptoms
Allergies (environmental, drug) Cardiovascular (hypertension, stroke) Constitutional ( weight loss, fevers) Ears, Nose, Mouth, Throat (upper respiratory) Endocrine (NID, ID, thyroid, hormonal) Eyes (GLC, AMD, Surgery) Gastrointestinal (ulcers, colitis) Genitourinary (STD) Luebbert Consulting & Training
Hematologic/Lymphatic (anemia, leukemia) Integumentary (psoriasis, eczema, rosacea) Musculo-skeletal(osteoarthritis, fibromyalgia) Neurological (MS, epilepsy) Psychiatric (depression, panic disorders) Respiratory (cigarette smoker, asthma) Luebbert Consulting & Training
If you investigate and document 1 area ◦ Problem Pertinent If you investigate and document 2 – 9 areas ◦ Extended If you investigate and document ◦ Complete (Can say all others are negative) Luebbert Consulting & Training
Past ◦ Ocular – cataract, AMD, GLC, surgery ◦ Medical – diabetes, hypertension Family History ◦ Ocular – cataract, AMD, GLC, surgery ◦ Medical – diabetes, hypertension Medication ◦ OTC and pharmaceutical Social ◦ Smoking, alcohol, hobbies Luebbert Consulting & Training
If you investigate and document 1 area ◦ Pertinent If you investigate and document 2 – 3 areas ◦ Complete ◦ Required if new patient Luebbert Consulting & Training
Billing level groundwork is laid Luebbert Consulting & Training
Problem Focused Extended Problem Focused Detailed Comprehensive Luebbert Consulting & Training
Problem Focused Expanded Problem Focused DetailedCompre- hensive HPI1-3 elements 1 – 3 elements 4 or more elements ROSNone1 element2 – 9 elements 10 or more elements PFSHNone 1 element2 or 3 elements Luebbert Consulting & Training
If you looked at it DOCUMENT IT!!!!! If the doctor looks at it DOCUMENT IT!!!!! Luebbert Consulting & Training
Be observant The doctor may not follow the ‘traditional’ sequence Document Luebbert Consulting & Training
Acuity Visual Fields (confrontation) Tonometry Ocular Motility (cover tests, EOM) Luebbert Consulting & Training
Adnexae (lids, lashes, puncta, orbit) Conjunctiva (palpebral, bulbar) Anterior Chamber Pupil / Iris Cornea Anterior Chamber Crystalline lens Retina (macula, foveal reflex, a/v ratio) Cup/Disc Luebbert Consulting & Training
Orientation to time, place, person General Constitution (mood) Luebbert Consulting & Training
Determine if additional groundwork is laid Luebbert Consulting & Training
1- 5 eye elements ◦ Problem Focused 6 – 8 eye elements ◦ Extended Problem Focused 9 – 11 eye elements ◦ Detailed Comprehensive 12 eye elements & 1 systemic element Luebbert Consulting & Training
Problem Focused Expanded Problem Focused DetailedComprehensive 1-5 elements 6-8 elements 9 – 11 elements 12 elements & 1 mental status Luebbert Consulting & Training
Are determined by the number of areas of the examination process investigated Luebbert Consulting & Training
May be a routine portion of the examination However Is not a medical test IS refractive (92000) Is to be separated from medical procedures Luebbert Consulting & Training
Diagnosis & Management Options Data Complexity Risk Luebbert Consulting & Training
Straight forward Low complexity Moderate complexity High Luebbert Consulting & Training
The doctor determines Levels ◦ Minimum ◦ Limited ◦ Moderate ◦ Extensive Luebbert Consulting & Training
Presenting Problem Diagnostic Procedure Management Options Minimal – Low – Moderate - High Luebbert Consulting & Training
Straight ForwardLow Complexity Moderate Complexity High Complexity Dx & Management Options MinimalLimitedMultipleExtensive Data Complexity MinimalLimitedModerateExtensive RiskMinimalLowModerateHigh Luebbert Consulting & Training
History Problem Focused Expanded Problem Focused DetailedCompre- hensive Exam Problem Focused Expanded Problem Focused DetailedCompre- hensive Decision Making Straight- Forward Low Complexity Moderate Complexity High Complexity E&M Code Luebbert Consulting & Training
History Dr Need Not Be Present Problem Focused Ex Problem Focused DetailedCompre- hensive Exam Dr Need Not Be Present Problem Focused Ex Problem Focused DetailedCompre- hensive Decision Making Dr Need Not Be Present Straight- Forward Low Complexity Moderate Complexity High Complexity E&M Code Luebbert Consulting & Training
Lower coding Lower billing level Luebbert Consulting & Training
Documentation Follow through Luebbert Consulting & Training
Leads to Higher levels of procedure levels Higher billing levels Luebbert Consulting & Training
Jill J Luebbert, CPOT, ABOC