Coding & Billing: Incorporating Lifestyle History Into Medical History

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NEW YORK—When you care about your patient, you learn about their lifestyle and incorporate these important facts into your medical history. Often, we think of the Lifestyle History as separate from the Medical History and the Demographic History. Because documenting the Medical History is essential to coding correctly and it is often time consuming, it’s not unusual to find that the Medical History has increased in importance and the Lifestyle questioning has decreased in importance.

One way to re-establish the importance of the Lifestyle History is to incorporate it into the Medical History. The Medical History has four components: chief complaint, HPI (History of Present Illness), ROS (Review of Systems), and PFSH (Past, Family and Social History). Within the PFSH is where your Lifestyle History should live. Specifically, the Lifestyle History is part of the Social History.

Technically, you only need to record one piece of Social History information in order to code that you took a social history. But often, to best manage the patient, you need to record more. Let’s use the HPI as an example. Only four items of the History of Present Illness are needed to reach the highest level, but it is not uncommon to find yourself documenting more because it helps you understand the patient and the condition you are treating. Likewise, with the Social History. Documenting as much as possible in order to understand the patient and the visual situations/problems they face is best patient management.

A simple outline to start discussions with patients in the Social History is: “Tell me how you use your eyes at home, school, work,and play.” Then, investigate these areas further. You can do this as a pre-examination history questionnaire or have a staff member ask these questions.

To bring alive the connection between the Social History and the patients’ eyewear prescriptions, follow a suggestion we learned at Transitions Academy from Dr. Diana Canto-Sims. Use a tray with four compartments to gather the prescriptions a patient brings into the office. You can label each compartment in various ways. The point you are making without saying it out loud is that the patient needs more than one pair of glasses.

The tray could look like this:


Then, use a similar tray when the patient goes into the optical to “shop” for the frames they are going to use to help improve their life in each of these areas.

We should always be looking for ways to integrate vision into medical and vice versa. Thinking of the Lifestyle History as part of the Medical History is a way to help unify the care we give to patients.

This article originally appeared on Review of Optometric Business (ROB) earlier this month.. Drs. Mark Wright and Carole Burns are professional editors of ROB. An extensive section of helpful articles about Coding and Billing issues and tactics are featured in a special section of the site, including Coding Connection: Maximizing Your Reimbursements, a special report.