The Post Op intermediate family are follow ups from a previous ocular surgery. The different surgeries that require post-operative visits include: Lasik (or other refractive surgery), Cataract surgery, and YAG surgery. What really distinguishes whether or not a post-surgical visit is classified as a Post-op is that the doctor is monitoring the patient’s post-operative recovery in place of the surgeon and, as such, is compensated out of the initial amount the surgeon billed the patient’s insurance for the surgery and all post-operative care. There are other surgeries after which the doctor may schedule some type of f/u, such as PI surgery, but this would technically be classified as a Glaucoma follow up (IOP check) since the surgeon is not billed for this visit. Many times the surgeon will have faxed records for the doctor to review; please check for these in the scanned documents section of the demographic page as they often contain important information such as current post-operative drop regimen and target prescription.

Note: Because we are participating in the postoperative care with the surgeon, IT IS OF THE UTMOST IMPORTANCE TO FAX THE RECORD OF EVERY SINGLE POST OPERATIVE VISIT TO THE SURGEON AFTER THE DOCTOR SIGNS OFF ON THE CHART. Particularly with cataract surgery, where the surgery on each eye is completed on separate days, the doctors findings after the first surgery could influence what goes into the second surgery. See the section below on how to print out records and fax.


Refractive Surgery Post Op

CONCEPT

The refractive surgery post-op is a follow up on Lasik (or other type of refractive surgery) the goal of which is to correct a patient’s refractive error. During this appointment, the doctor will check on how well the patient’s eye is healing from the trauma of surgery as well as how close the patient’s eyes are to the target prescription.

Please watch the following video on Lasik.

WORKUP ORDER

Complete autorefraction, visual acuity, expedited medical history (specifically any drops with regimen the patient was prescribed after the surgery). Inquire if there were any complications during the surgery and if the patient has developed any new symptoms after the surgery (such as new flashes or floaters in their vision)



CHARTING CHECKLIST

  • Layout: Intermediate.

  • Hx/Meds: Forward and update

  • Workup: Enter Lasik Post-op as the chief complaint. Fill in VAs, pupils, and EOMs. Enter the autorefraction into the refraction table along with the doctors refraction as a BVA.

  • Exam: Forward anterior and posterior findings (delete the posterior findings if the doctor does not complete) and update based on the doctors findings. Forward Myopia in the plan and make it the #1 diagnosis for the appointment. Update plan to reflect all recommendations from that appointment.

  • Routing: Check the 90001 Post-op Refractive box. Enter “Lasik Post-op (please post); no charge to patient” if it is the first Lasik post-op. Enter “Lasik Post-op (already posted); no charge to patient” if it is a subsequent Lasik post-op (verify that the post-op fee was posted previously on the ledger). Also indicate any additional follow up that needs scheduled in the additional notes box.

  • Fax records to the surgeon after the doctor signs off.

Cataract Surgery Post op

CONCEPT

Cataract surgery has two goals: remove a patient’s crystalline lens which has become opaque with cataracts and insert an artificial lens that will bring each eye’s refractive error as close as possible to a target prescription. After the surgery, the patient will have several post-op visits where the doctor will check on how well the patient’s eye is healing from the trauma of surgery as well as how close the patient’s eyes are to the target prescription. Cataract surgery post-ops are completed at 1 day, 1 week, and 1 month intervals for each eye that undergoes surgery with a new glasses Rx finalized at the 1 month visit of the 2nd eye. A patient never has both eyes completed on the same day (usually they are separated by at least a couple weeks); because of this, the 1 month follow up on the first eye will often double as the 1 week follow up on the second eye, usually resulting in a total of three post-operative appointments (the surgeon almost always completes the 1 day follow up for each eye). See the example below for what this might look like.

  • Pt has OD cataract sx > 1 day OD post-op > 1 wk OD post-op > Pt has OS cataract sx > 1 day OS post-op > 1 wk OS post-op > 1 mos OS final post-op w/dfe and final glasses Rx

Please watch the following video on cataract surgery

WORKUP ORDER

Complete autorefraction, visual acuity, expedited medical history (specifically any drops with regimen the patient was prescribed after the surgery). Inquire if there were any complications during the surgery and if the patient has developed any new symptoms after the surgery (such as new flashes or floaters in their vision)

CHARTING CHECKLIST

  • Layout: Intermediate.

  • Hx/Meds: Forward and update

  • Workup: Enter Cataract surgery post-op as the chief complaint. Fill in VAs, pupils, and EOMs. Enter the autorefraction into the refraction table along with the doctors refraction as a BVA (at the final post-op the doctor will finalize a new glasses prescription).

  • Exam: Forward anterior and posterior findings (delete the posterior findings if the doctor does not complete) and update based on the doctors findings. If it is the first post-operative visit, enter a new diagnosis of “Presence of Intraocular lens” in the plan, make it the #1 diagnosis. Update plan to reflect all recommendations from that appointment.

  • Routing: Check the 66984 Post-op Cataract box. Enter “Cataract surgery Post-op (please post); no charge to patient” if it is the first Cataract surgery post-op. Enter “Cataract surgery Post-op (already posted); no charge to patient” if it is a subsequent cataract surgery post-op (verify that the post-op fee was posted previously on the ledger). Also indicate any additional follow up that needs scheduled in the additional notes box.

  • Fax records to the surgeon after the doctor signs off.

YAG Surgery Post op

CONCEPT

The YAG surgery post-op is a follow up on YAG surgery. YAG surgery is sometimes necessary after cataract surgery if the capsule that holds the artificial lens starts to become cloudy. The surgeon uses a laser to open a window in the back of the capsule so that light can pass through to the retina without being scattered through the cloudy capsule. During the follow up appointments, the doctor will check on how well the patient’s eye is healing from the trauma of surgery as well as how well the patient is able to see now that there is a window in the capsule.

Please watch the following video on YAG surgery.

WORKUP ORDER

Complete autorefraction, visual acuity, expedited medical history (specifically any drops with regimen the patient was prescribed after the surgery). Inquire if there were any complications during the surgery and if the patient has developed any new symptoms after the surgery (such as new flashes or floaters in their vision)

CHARTING CHECKLIST

  • Layout: Intermediate.

  • Hx/Meds: Forward and update

  • Workup: Enter YAG Post-op as the chief complaint. Fill in VAs, pupils, and EOMs. Enter the autorefraction into the refraction table along with the doctors refraction as a BVA.

  • Exam: Forward anterior and posterior findings (delete the posterior findings if the doctor does not complete) and update based on the doctors findings. Forward Presence of Intraocular Lens in the plan and make it the #1 diagnosis for the appointment. Update plan to reflect all recommendations from that appointment.

  • Routing: Check the 66821 Post-op/YAG box. Enter “YAG Post-op (please post); no charge to patient” if it is the first YAG post-op. Enter “YAG Post-op (already posted); no charge to patient” if it is a subsequent YAG post-op (verify that the post-op fee was posted previously on the ledger). Also indicate any additional follow up that needs scheduled in the additional notes box.

Faxing Records

To fax records we must first print them out after the doctor signs off on the chart indicating that it is complete. To print out records, click the print button on the menu bar and select the “complete” option.

This compiles the chart into a text document. From here, click on file in the menu bar and select the print option.

This opens up the printing window. Select the printer you want to send it to, the click on properties to the right.

We need to do this, because the printer’s default setting is to print on both sides, but to fax we need to have everything printed on only one side. On the finishing tab, select the one sided printing option then click OK.

This will take you back to the previous window. Now, select print and it should print out at the printer you chose.

Next we must figure out where to fax the records to. In the OA helpful things folder (subfolder cheat sheets) there is an excel doc titled Consults that lists all the major offices we consult/comanage with along with their phone#, fax#, and addresses. Find the fax number for the surgeon’s office on the list and have it on hand when you are ready to fax the records.

Please take the Checkpoint Quiz