Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive, established patient, 1 or more visits
CPT4 code
Name of the Procedure:
Comprehensive Ophthalmological Services: Medical Examination and Evaluation, With Initiation or Continuation of Diagnostic and Treatment Program; Comprehensive, Established Patient, 1 or More Visits.
Summary
A comprehensive ophthalmological examination and evaluation involves a thorough assessment of an established patient's eye health. This procedure includes reviewing the patient's medical history, conducting various eye tests, and formulating a diagnosis and treatment plan, which can span one or more visits.
Purpose
The purpose of this comprehensive eye examination is to diagnose and manage a wide range of eye conditions and diseases. The primary goals are to detect any vision problems early, monitor existing conditions, and initiate or continue appropriate treatment to maintain or improve vision health.
Indications
- Changes in vision such as blurred vision, double vision, or loss of vision.
- Symptoms like eye pain, redness, or discharge.
- Monitoring chronic conditions such as glaucoma, diabetes, or hypertension that can affect eye health.
- Routine check-up for patients with a history of eye diseases.
- Follow-up care for patients currently under treatment for eye conditions.
Preparation
- Patients may need to bring their current glasses or contact lenses and a list of any medications they are taking.
- Specific instructions, such as not wearing contact lenses for a certain period before the exam, may be given.
- No fasting or significant medication adjustments are typically required.
Procedure Description
- Medical History Review: The healthcare provider will review the patient's medical history, including any previous eye problems and treatments.
- Visual Acuity Test: The patient will read letters on a chart to assess how well they see at different distances.
- Refraction Assessment: Determines the lens prescription needed for glasses or contact lenses.
- Ocular Motility Test: Checks eye alignment and movements.
- Visual Field Test: Assesses peripheral vision.
- Tonometry: Measures eye pressure to screen for glaucoma.
- Slit Lamp Examination: Detailed inspection of the eye's front structures using a microscope with a bright light.
- Retinal Examination: The back of the eye is examined, often following pupil dilation, to evaluate the retina and optic nerve.
- Diagnostic Tests: Additional tests like OCT (optical coherence tomography) or fundus photography may be performed as needed.
- Anesthesia or sedation is usually not required; however, dilating drops may cause temporary discomfort and light sensitivity.
Duration
The procedure typically takes about 60-90 minutes, but this can vary based on the specific tests required and the findings.
Setting
This procedure is usually performed in an outpatient clinic or an ophthalmologist's office.
Personnel
- Ophthalmologists: Medical doctors specializing in eye and vision care.
- Optometrists: Primary healthcare professionals for routine eye care.
- Ophthalmic Technicians: Assist with performing tests and initial evaluations.
Risks and Complications
- Temporary discomfort from bright lights or dilating drops.
- Rare allergic reactions to eye drops.
- Possible transient blurriness or light sensitivity post-examination.
- Serious risks are rare but may include infection from equipment contact.
Benefits
- Early detection and management of eye conditions can prevent vision loss.
- Accurate prescriptions for glasses or contact lenses.
- Monitoring and treating chronic conditions to prevent complications.
- Improved overall eye health and vision.
Recovery
- Patients may experience blurred vision or sensitivity to light for a few hours if dilating drops are used.
- Normal activities can usually be resumed immediately, except for tasks requiring clear vision, such as driving, if dilation is performed.
- Patients should follow any specific care instructions provided by their eye care provider.
- Follow-up appointments may be recommended to monitor treatment progress or further evaluate findings.
Alternatives
- Limited eye examination: Focuses on specific concerns but may miss broader health issues.
- Online vision tests for eyeglass prescriptions: Convenient but lack comprehensive diagnostic capabilities.
- Regular follow-up with primary care for general health monitoring if eye-specific concerns are not prominent.
Patient Experience
- The patient may feel minor discomfort from the bright lights or dilating drops used in the examination.
- The tests are generally non-invasive and painless.
- Comfort measures and explanations provided by the healthcare team help ensure a smooth experience.
- Pain management is usually unnecessary unless specific interventions are performed.
By providing a detailed and thorough examination, comprehensive ophthalmological services aim to protect and improve eye health, ensuring the best possible outcomes for established patients.