Many of you still don’t ask patients for their family vision history, according to the results of Jobson Optical Research’s 2012 Adult Consumer Eye Exam Experience. Only about half–50.7 percent–of respondents report that they were asked for this information at their last eye exam. That percentage is down slightly from 2011 when 51.8 percent said they had been asked for family vision history. Some 45.6 percent said they were asked for family vision history at their eye exam in 2010.
One of the largest areas of practice growth in the last few years has been in the delivery of medical eyecare. Medical documentation is essential to reimbursement when providing medical eyecare. In medical documentation required for the 99000 Evaluation and Management codes, a Family History is required for a new patient comprehensive exam.
A medical history for the 99000 Evaluation and Management codes has four parts:
1) The medical reason for the visit (also called the chief complaint)
2) History of present illness (i.e.: the history of the reason for the visit)
3) Review of systems
4) Past, family and social history
For a comprehensive exam for a new patient to be bill as a 99000 E/M visit, you need to document for a Past, Family and Social History:
1) A past history
2) A family history
3) A social history
The purpose of the medical Family History is to look for diseases or hereditary conditions which may place the patient at risk. The easiest way to do this is to put these questions on a pre-examination history questionnaire. The doctor just needs to read and sign-off on the history form to show that it was reviewed.
Your action plan for this week is to review your patient pre-examination history questionnaire making sure it adequately asks questions about the patient’s family history.
To purchase the 2012 Adult Consumer Eye Exam Experience, visit www.jobsonresearch.com/insight_eyeexam