Documenting Cataract Postoperative Care

Encompass enables you to document a visit for a patient who is coming in after cataractClosed Clouding of the natural lens of the eye, usually caused by aging in conjunction with such risk factors as exposure to the sun's UV rays, smoking, steroid intake, and diabetes. Symptoms include blurred vision, glare, halos around lights, colors that are less bright, a cloudy spot in vision, and temporary vision improvement. surgery. This topic provides an overview of how

To document a cataract postoperative visit

  1. Create a new visit for the patient.
  2. Click the CC/HPI/ROS button on the action bar.
  3. Click Add a New Chief Complaint.

  4. Search for and select Postop Cataract.

  5. Indicate which eyes the cataract surgery was performed on using the eye diagram.

  6. Click Continue.

    Alternatively, you can follow up on a past diagnosis by selecting it from the Follow Up CC window in the Manage CC/HPI area and clicking Save and Continue.

  7. Under Is this a new presentation, or a follow-up?, select the check bubble for Follow Up Postop Surgery.
  8. Record additional information as needed.

  9. Click Save.

  10. Complete the Review of Systems and Vision Exam section as necessary depending on your examination.
  11. Save your work and click the Ocular Exam button on the action bar.
  12. Document the Eye Exam, making sure to indicate whether or not you dilatedClosed To expand the pupil of the eye. Pupils are most commonly dilated during the internal exam. Occasionally pupils are dilated in disease cases as a means of preventing the iris from sticking to the lens of the eye. the patient.
  13. Select the cataract diagnosis you are following up on.
  14. Click Custom Findings.
  15. In the text box, type "Clear and Centered PCIOL".
  16. Under Finding Relates to, select sle lens.
  17. Under Remember, select Always remember this finding for this Dx.
  18. Click Done.

  19. Document the following plans:

    • Post Op Evaluation Cataract. This plan will add a 99024 CPT codeClosed Current Procedural Terminology. The numeric codes that are submitted to insurers for payment. Every billable procedure has its own individual CPT code. to the visit. If you don't want this code to generate, select No from the drop-down list. Also, make sure to select the Location as well as the Postop Day OD and Postop Day OS to meet Quality requirements.
    • Comanagement. Specify the Operated Eye(s), and under Relinquish/Assumption of Care, select Assuming Care. You can also modify the Comanagement CPT Code from here.
    • Set Global Period. Select the Location, select the type of surgery from the Surgery Picklist, set the Other surgery global period to 90, and enter the Date of Surgery.

    • F/U for Next Visit Cataract. Set the follow up details.

      For all subsequent visits, you only need to use the Postop Cataract diagnosis and the Post Op Evaluation Cataract plan, where you can enter all the details of your evaluation. Comanagement and Set Global Period only need to be applied to the initial "Day 1" visit.

  20. Click Save Visit Note.

  21. Click Finalize Visit on the action bar, and confirm your finalization.

    Due to the amount of steps required to document a postoperative visit, it's recommended to create protocols to save you time. You might create a protocol for "Day 1 Postop Cataract", "Week 1 Postop Cataract", and so forth for ODClosed Oculo Dextra. Latin abbreviation for right eye., OSClosed Oculo Sinestra. Latin abbreviation for left eye., and OUClosed Oculo Uterque. Latin abbreviation for both eyes.. For information on creating protocols, go to Working With Protocols.