Physical Exam Levels
Part two of our three-part series deals with physical exam components.

Accurate coding of evaluation and management visits requires proper determination of three key components: history, physical examination and medical decision-making. January’s column focused on determining the proper level of history. This month, we’ll focus on the physical exam. The number of exam elements you perform is a matter of clinical judgment with regards to the nature and complexity of the chief complaint. The Centers for Medicare and Medicaid Services (CMS) recognize the eye as a single organ system and has designated the physical examination elements of the eye as 12 ophthalmic elements and two mental status elements. (See “Patient History Elements,” right.)
Document appropriately
You may designate normal findings as normal or negative in your medical record. However, you cannot describe abnormal findings as simply abnormal or positive without appropriate elaboration and description of the abnormal findings. For example, you can document a normal corneal stroma as “corneal stroma negative” or “corneal stroma clear.” However, simply recording “corneal stroma positive” isn’t sufficient. Clearly define the abnormality: corneal stroma O.D. with 1mm round, opaque opacity at 3 o’clock near the limbus. Simply add up the number of medically necessary exam elements you completed. (See “Number of patient history elements required for each level,” below .)

Patient History Elements
Ophthalmic Examination Elements
• Visual acuity
• Gross visual field testing
• Ocular motility
• Pupils and irises
• Ocular adenexae (including lids, lacrimal
glands and drainage, orbits and preauricular
lymph nodes)
• Bulbar and palpebral conjunctiva
• Slit lamp examination of the corneas
(including epithelium, stroma and
endothelium)
• Slit lamp examination of the anterior chamber
(including depth, angles, cells and flare)
• Slit lamp examination of the lenses
(including clarity, anterior and posterior
capsules, nucleus and cortex)
• Intraocular pressure
• Optic discs through dilated pupil unless
contraindicated
• Posterior segments through dilated pupil
unless contraindicated
Mental Status Elements
• Orientation to time, place and person
• Mood and effect.

Number of patient history elements required for each level

Problem-focused
One to five elements

Expanded problem-focused
Six to eight elements

Detailed
Nine to 13 elements

Comprehensive
14 (all 12 ophthalmic and both mental status elements)

DR. MACK IS DIRECTOR OF CLINICS AT THE OHIO STATE UNIVERSITY COLLEGE OF OPTOMETRY. E-MAIL HER AT CMACK@OPTOMETRY.OSU.EDU.