1. Jill J Luebbert, CPOT, ABOC

2. Luebbert Consulting & Training

3.  99000’s  92000’s Luebbert Consulting & Training

4.  How you document determines the billing level Luebbert Consulting & Training

7.  Pretest  Chairside documentation Luebbert Consulting & Training

8.  It never happened Luebbert Consulting & Training Xxxxxxxx Xxxxxxxxxxx xxxxxxxxxxxx

9. SOAPSOAP Luebbert Consulting & Training

10.  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

12.  Subjective Data  HPI ◦ History of Present Illness  PFSH ◦ Past, Family, and Social History Luebbert Consulting & Training

13.  ‘What brings you here today?’ Luebbert Consulting & Training

14.  Determines what happens next  Is the chief complaint medically oriented? Luebbert Consulting & Training Refractive - 92000 Medical - 99000

15.  Vision cloudy  Feel itchy  Teary  Vision fluctuates  Shadows  Headaches  Red Luebbert Consulting & Training

16.  NOW………….  99000 CODES Luebbert Consulting & Training

17.  DOCUMENT!!!!!!!!! Luebbert Consulting & Training

18.  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

19.  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

20.  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

21.  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

22.  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

23.  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

24.  If you investigate and document 1 area ◦ Pertinent  If you investigate and document 2 – 3 areas ◦ Complete ◦ Required  if new patient Luebbert Consulting & Training

25.  Billing level groundwork is laid Luebbert Consulting & Training

26.  Problem Focused  Extended Problem Focused  Detailed  Comprehensive Luebbert Consulting & Training

27. 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

28.  If you looked at it  DOCUMENT IT!!!!!  If the doctor looks at it  DOCUMENT IT!!!!! Luebbert Consulting & Training

29.  Be observant  The doctor may not follow the ‘traditional’ sequence  Document Luebbert Consulting & Training

30.  Acuity  Visual Fields (confrontation)  Tonometry  Ocular Motility (cover tests, EOM) Luebbert Consulting & Training

31.  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

32.  Orientation to time, place, person  General Constitution (mood) Luebbert Consulting & Training

33.  Determine if additional groundwork is laid Luebbert Consulting & Training

34.  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

35. Problem Focused Expanded Problem Focused DetailedComprehensive 1-5 elements 6-8 elements 9 – 11 elements 12 elements & 1 mental status Luebbert Consulting & Training

36.  Are determined by the number of areas of the examination process investigated Luebbert Consulting & Training

38.  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

39.  Diagnosis & Management Options  Data Complexity  Risk Luebbert Consulting & Training

40.  Straight forward  Low complexity  Moderate complexity  High Luebbert Consulting & Training

41.  The doctor determines  Levels ◦ Minimum ◦ Limited ◦ Moderate ◦ Extensive Luebbert Consulting & Training

42.  Presenting Problem  Diagnostic Procedure  Management Options Minimal – Low – Moderate - High Luebbert Consulting & Training

43. Straight ForwardLow Complexity Moderate Complexity High Complexity Dx & Management Options MinimalLimitedMultipleExtensive Data Complexity MinimalLimitedModerateExtensive RiskMinimalLowModerateHigh Luebbert Consulting & Training

44. 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 9920199202992039920499205 Luebbert Consulting & Training

45. 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 9921199212992039921499215 Luebbert Consulting & Training

46.  Lower coding  Lower billing level Luebbert Consulting & Training

47.  Documentation  Follow through Luebbert Consulting & Training

48.  Leads to  Higher levels of procedure levels  Higher billing levels Luebbert Consulting & Training

50. Jill J Luebbert, CPOT, ABOC jill@jjlconsulting.com www.jjlconsulting.com