Documenting Gonioscopy

You can document gonioscopy within the Ocular Exam Room. Eyefinity EHR enables you to record your evaluation in several different ways.

  • To record your overall findings, use the Gonio section of the Eye Exam.
  • To visually record findings, select Gonioscopy Drawing under Glyphs. For more information on using glyphs, see Using Glyphs.

  • To record that gonioscopy was performed in relation to a specific diagnosis, select the Gonioscopy plan.

    If you're billing for gonioscopy, make sure to select Gonioscopy as a plan. This is what generates a billing code. Simply documenting findings under the Gonio tab of the Eye Exam or applying glyphs will not generate a gonioscopy billing code.

This topic covers how

  1. Open the Ocular Exam Room.
  2. Click Perform Exam.
  3. Select Eye Exam from the list of exam sets.
  4. Click the Gonio tab.
  5. Select the check box for gonioscopy.
  6. Record your findings.

  7. Click Done with exam.

    Your findings are added to the visit note. If you're done documenting in the Ocular Exam Room, make sure to click Save Visit Note.

    Clicking Gonioscopy Drawing Mode enables you to apply glyphs the same way you would using the Gonioscopy Drawing option in the Ocular Exam Room. Click Resume Exam to resume documenting the Eye Exam.

  1. Open the Ocular Exam Room.

  2. Click Gonioscopy Drawing under the Glyphs section.

    A list of glyphs appears in the Plans section.

  3. Select the glyph you want to record.
  4. Click the location on the eye diagram where you want to apply the glyph.

  5. Use the Rotate and Scale options to modify the appearance of the glyph.

    To continue placing glyphs, repeat Steps 3-5.

  6. When you're finished applying glyphs, click Done with this Diagnosis and Plan: Save Changes and Update Preview of Note.

    The glyphs appear the same way a diagnosis would at the bottom of the screen. Selecting glyphs also backfills any normal findings you previously recorded as a part of the Eye Exam.

    If you're done documenting in the Ocular Exam Room, make sure to click Save Visit Note.

  1. Open the Ocular Exam Room.
  2. Select a diagnosis.
  3. Indicate the location of the diagnosis by clicking the eye diagram.
  4. Indicate the status of the diagnosis by clicking Status or New Dx.
  5. Record any findings as necessary.
  6. Select the Gonioscopy plan.
  7. Indicate the Location and Reliability of study.
  8. Record additional notes in the Medical Necessity box if gonioscopy was medically necessary.
  9. Click the Assessment and Plan tab.
  10. Indicate your Assessment using the drop-down list.

  11. Select the check box for any evaluation or treatment option that applies.

    Your selections will be remembered and will default in the future whenever you select the Gonioscopy plan.

  12. Click Done.

  13. Record any other plans as necessary.
  14. Click Done with this Diagnosis and Plan: Save Changes and Update Preview of Note.

  15. Click Save Visit Note.

    The billing code for gonioscopy appears in the coding section of the Visit Overview.