The Plan
The Plan is a numbered list of all diagnoses that were evaluated during the patient’s visit. Each diagnosis will include an assessment of the status of the diagnosis and a corresponding plan of treatment.
The Plan is found in the Dx/plan table, found on the right side of the Exam tab.
Adding Diagnoses
To add a diagnosis to the plan, use the three dot ellipsis in the upper left corner of the Dx/plan table. Doing so will open up a blank diagnosis template.
Next, you can search for the diagnosis by code or name (most of the time it will be easier to enter the diagnosis name in the description box; for difficult to find diagnoses, reference the diagnoses cheat sheet in the OA helpful things folder). Also number the diagnosis in the box in the upper left corner.
After entering the name of the diagnosis in the description box, press F7 or use the drop down. This will open up a new window with a list of possible diagnosis options to select from. Double click the most appropriate one.
Doing so will populate the diagnosis code and complete description. Many diagnoses also autopopulate laterality (right eye, left eye, both) as well as a basic assessment and plan (to be discussed further below.
Make any additional changes and press save. This will add the diagnosis to the plan table sorted by date and numerical order.
Diagnosis Order
All diagnoses for a visit are also numbered according to the insurance billed as well as level of importance. This number is entered in the Order box in the upper left corner of the diagnosis entry (see example above). Here are the general rules about how to order applicable diagnoses for exams and intermediates.
Exams
1) If billing to a vision insurance, unless using EMEC under a VSP plan, the #1 diagnosis must be a refractive diagnosis (myopia, hyperopia, presbyopia, etc.)
2) if billing to medical insurance or if coordinating benefits using EMEC the #1 diagnosis must be a medical diagnosis, preferably the diagnosis linked to the chief complaint (see module for Chief Complaint), and the refractive diagnosis should the last diagnosis.
3) If the patient has Diabetes, Hypertension, and/or High cholesterol, at least one must be in the top four diagnoses (giving preference to diabetes). If applicable, have all three in the top four diagnoses unless making room for diagnoses that apply to rule 4.
4) Any diagnosis that is the basis for a billed procedure (i.e. fundus photos, pachemetry, Epilation) or a consult to an opthalmologist must be in the top four diagnoses.
5) All other diagnoses can be any order.
This is an example of ordering for an exam billed to Vision Insurance. The refractive error (presbyopia) is #1, Diabetes is #2, POAG-B because of the Fundus photos is #3, and Pinguecula is #4.
This represents the same exam as above except billed to a medical insurance (or coordinating benefits using . The refractive error is now the last diagnosis, and Diabetes has been moved to #1. Note: Diabetes unlike Hypertension or High Cholesterol can, and should, serve as the #1 diagnosis for a medically billed exam for a diabetic patient.
Intermediates
1) The #1 diagnosis should be the diagnosis which is the reason for the appointment (Presbyopia for an Rx check, POAG-B for and IOP check, Dry Eye for an Ilux, etc.)
2) All other diagnoses can be in any order; but only include new diagnoses, diagnoses which the doctor specifically references, or which are the basis for a billed procedure or consult to an opthalmologist.
This is an example of plan order for an IOP check. POAG-B which is the diagnosis being monitored during an IOP check is #1. The doctor also discussed with the patient their diabetic status and how it relates to glaucoma risk factors, and so it was entered as #2.
Please watch the following video which goes over the basics of how to enter and order plan items as well as the basics of how to complete assessments and tx plans which are covered in more detail below.
Assesment
All diagnoses in the plan will have an assessment of the status of the diagnosis. There are three possible components to an assessment and each will be separated by a comma.
1) New problem vs. established problem: A brand new diagnosis is considered a new problem. If it was discovered at a previous visit, it is an established problem.
-There is a third option which is new problem to doc. This is used the first time a doctor is observing a previously established diagnosis
Example: Dr. Lay diagnosed POAG at the patient’s annual exam, but Dr. Johnson later sees the patient, for the first time, for an IOP check. Dr. Lays assessment would say new problem; Dr. Johnson’s assessment would say new problem to doc. When Dr. Lay sees them for their exam the following year, his assessment would say established problem.
2) Stable vs. worsening vs. improving: For established problems only, the doctor should indicate whether the diagnosis is stable, worsening, or improving.
Example: A patient is seen for an emergency and is diagnosed with Gr. 1 SPK. They are seen for a follow up and the SPK is now Gr. 2, the assessment would say worsening. They are seen for a third follow up and now the SPK is only Trace, the assessment would say improving. They are seen for a fourth follow up and the SPK is still Trace, the assessment would say stable.
3) Add workup vs. No add workup: If the doctor requests any follow-up on this diagnosis prior to the next full exam then there is add workup required. If the patient is ok until their next full exam then there is no add workup required.
Example: A patient is seen for their exam and their plan includes presbyopia and POAG-B. Presbyopia will not be monitored again until the next annual, this assessment would say no add workup. POAG-B will be monitored with an IOP check in 3 months, this assessment would say add workup
Here the doctor has observed this diagnosis before, it has not progressed, and she wanted an IOP check to follow up on it before the next exam.
Here it was the first time a doctor observed a previously established diagnosis, there was no progression, and there was no follow up needed for this diagnosis until the next full exam.
In this example, the patient received a brand new diagnosis of Pinguecula. Because the diagnosis was new, it could not be stable, worsening, or improved; therefore this component of the assessment is absent. Lastly, there was not follow up needed for the Pinguecula until the next exam.
Plan
The “plan” is the plan of treatment for a specified diagnosis. It includes a summary of everything which is to be done moving forward to treat a specific diagnosis until an established time for revaluation.
There are three essential components that must be in every plan.
1) Ed pt on condition: After the doctor establishes a diagnosis, they initially educate the patient on the nature of the diagnosis so that they can better partner with the doctor on the established plan of treatment.
2) Monitor x _: The doctor establishes a set time for revaluation of the diagnosis. For many diagnosis this will be Monitor x 1 year (i.e. at the next annual exam). However, other diagnoses will merit further testing or present enough of a risk of complication that the patient needs to return prior to their annual exam. Examples of this would be Monitor @ IOP check x 3 mos, Monitor w/Thresh/OCT-RNFL x 4-6 mos, Schedule dry eye f/u x 2-3 wks, etc.
3) RTO if problems/VA changes: After the doctor establishes a time for revaluation of the diagnosis, the doctor tells the patient that if there are any problems with their eyes or changes in vision in the interim they should return to the office (RTO) rather than wait for their next appointment.
Less complicated diagnoses may only have these three components in the plan. However, for more complicated diagnoses with more involved treatment plans, these three components will be used as bookends. All plans should begin with “Ed pt on condition” because this forms the foundation for all treatment to follow; and all plans should end with “Monitor x _. RTO if problems/VA changes” because this sets an expiration date on the current plan of treatment. Anything else related to the treatment of the specified diagnosis should be in between these bookends.
Here are some examples.
This is a standard plan for a refractive error diagnosis. In between the bookends you see the level of recommendation for updating glasses (Prescribed). This patient also wears contacts, and so it is indicated that the patient is ok to order up to a one-year supply of their current brand of contacts (1 day moist). Also note that whenever a patient’s contact lens prescription is finalized it is also included in parentheses how frequently the contacts should be changed (wear time) and whether or not their specific brand is approved for extended wear (i.e. sleeping in their contacts).
This is the default plan which will load whenever a diagnosis of diabetes is entered. A specific aspect of patient education is highlighted here (the importance of controlling blood sugar levels and returning for yearly dilated eye exams). Testing which is billed to a patient’s insurance (Retinal photos in this case) is usually included in the plan of the diagnosis which merited it. Also, any communication between a patient’s care providers is usually also included in the plan.
Standard plan for cataracts. It is usually specified whether the condition has progressed enough to merit cataract surgery. When that point is reached, “monitor w/o sx” would change to “schedule cataract sx consult w/opthalmologist” and “annual x 1 year” would change to “monitor w/post-ops”
Here is an example of a diagnosis that the doctor observed at the clinical level, but had not yet progressed to the point that the patient is experiencing symptoms. In such cases this is indicated by saying “pt is currently asymptomatic”.
Adding Diagnoses vs. Forwarding Diagnoses
During a complete exam, the doctor will be evaluating all of a patient’s current ocular diagnoses. Therefore, all of a patient’s current ocular diagnoses should be represented in the plan for that day.
If a patient is new to the practice, all of these diagnoses will have to be individually added as demonstrated above.
If a patient is Established, begin by forward all plan items from the last Comprehensive Exam (unless they are resolved), then add any new diagnoses based on the doctor’s findings that day. To forward a diagnosis, scroll up in the plan table until you find diagnoses corresponding to the last exam date, then, one by one, right click on a diagnosis and select Forward or Forward/Edit from the dropdown. If their last visit was their comprehensive exam then you can use the Forward DOS option which will forward all diagnoses from the last date-of-service.
common diagnoses and what to search for in the plan tab
Common diagnosis codes and descriptions can be found in the “OA Helpful Things” folder (sub folder cheat sheets) on the server desktop.
Tobacco, Hypertension, High Cholesterol, and Diabetes Plan Items
Here a few key things to remember when adding these items into your EMR chart.
Tobacco: At every routine eye visit we check on the status of the patient’s use of tobacco products. Make sure to note in their chart if they are currently, never, or former smoker (if there is no change to their status from their previous visit then make sure to forward the status on the Health History table so that it reflects the current date of service). If the patient does use tobacco products, make sure to add a plan entry stating that we educated the patient on the risk of using tobacco products and how it relates to the eyes. Use ICD-10 code Z72.0 for tobacco use in the plan.
Hypertension: At every routine eye visit we review and update the patient’s medical history. Make sure to note in the Health history, ROS, and plan if the patient has been diagnosed with hypertension. Also be sure to record the current hypertension medication and what their blood pressure was on the date of service. Essential Hypertension is documented on the plan using ICD-10 code I10.
High Cholesterol: At every routine eye visit we review and update the patient’s medical history. Make sure to notate in the health history, ROS, and plan if the patient has been diagnosed with high cholesterol. Also record their current cholesterol medication in the medication tab. High Cholesterol (other hyperlipidemia) is documented on the ledger using ICD-10 code E78.49.
Diabetes: At every routine eye visit we review and update the patient’s medical history. Make sure to notate in the health history, ROS, and plan area if the patient has been diagnosed diabetic, documenting whether it is Type I or Type II, and what medication(s) they are currently using. In the plan note if it’s an oral medication (Z79.84), insulin (Z79.4), or both. Another step you have to take for diabetic patients is to add their most recent A1C and most recent daily blood sugar measurement to their record. A diabetic report must be filled out, attached to the patient's scanned documents, and sent to their PCP or endocrinologist. There are a large number of ICD-10 codes for diabetic status; code to the highest degree of specificity possible.
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