Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; intermediate, new patient
CPT4 code
Name of the Procedure:
Ophthalmological Services: Medical Examination and Evaluation with Initiation of Diagnostic and Treatment Program; Intermediate, New Patient
Summary
This procedure involves a detailed eye examination for new patients, focusing on diagnosing and starting treatment for eye-related issues. It is more thorough than a basic check-up but not as extensive as a comprehensive exam.
Purpose
This examination addresses vision problems, eye diseases, and other ocular issues. The goal is to identify any abnormalities, diagnose conditions, and initiate an appropriate treatment plan to preserve or improve vision.
Indications
- Blurred vision
- Eye pain
- Redness or swelling in the eyes
- Unusual eye discharge
- Visual disturbances like floaters or flashes
- Patients with risk factors for eye diseases, such as diabetes or hypertension
Preparation
- Bring any previous medical records and a list of current medications.
- Wear your current glasses or contact lenses.
- No specific preparation like fasting is required, but avoid wearing eye makeup.
Procedure Description
- Patient History: Discussion of medical history and current symptoms.
- Initial Tests: Vision tests using charts, eye pressure measurement (tonometry), and pupil dilation.
- Comprehensive Examination: Use of specialized instruments to examine the front and back parts of the eye, including a slit-lamp and ophthalmoscope.
- Diagnostic Tests: If needed, additional tests like retinal imaging or visual field tests may be conducted.
- Treatment Plan: Based on findings, a treatment plan is outlined, which may include medications, lifestyle changes, or a referral to a specialist.
Duration
The procedure typically takes about 45 to 60 minutes.
Setting
This procedure is performed in an ophthalmologist's office or an outpatient clinic.
Personnel
- Ophthalmologist (eye doctor)
- Ophthalmic technician or assistant
- Sometimes, a nurse may be involved
Risks and Complications
- Temporary discomfort from bright lights or eye drops
- Rarely, allergic reactions to diagnostic eye drops
- Potential for transient blurred vision post-exam due to pupil dilation
Benefits
- Accurate diagnosis of eye conditions
- Timely initiation of appropriate treatment
- Improved vision and prevention of further ocular issues
Recovery
- Most patients can return to normal activities immediately.
- Temporary effects like light sensitivity and blurred vision from dilation may last a few hours.
- Follow-up appointments as needed based on diagnosis and treatment plan.
Alternatives
- Basic eye exams for routine checks (less thorough)
- Comprehensive eye exams for a more in-depth evaluation
- Optometrists for non-surgical eye care
Pros: Intermediate exams are thorough enough to diagnose and start treatment but less time-consuming than comprehensive exams.
Cons: May not identify all complex or rare eye conditions.
Patient Experience
- During the exam, patients might feel mild discomfort from bright lights or eye drops.
- After the procedure, temporary blurred vision and light sensitivity are common but resolve within a few hours.
- Pain management and comfort measures, such as sunglasses, may help alleviate post-exam sensitivity.