Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; comprehensive, new patient, 1 or more visits
CPT4 code
Name of the Procedure:
Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; comprehensive, new patient, 1 or more visits.
Common name(s): Comprehensive eye exam for new patients.
Summary
A comprehensive eye exam for new patients involves a thorough evaluation of the eyes to diagnose and treat various eye conditions. The exam may occur over one or more visits and includes tests to assess visual acuity, eye movement, and ocular health.
Purpose
This exam addresses a wide range of eye conditions such as vision problems, eye infections, and diseases like glaucoma or cataracts. The goal is to diagnose any existing issues and initiate a treatment plan to maintain or improve eye health and vision.
Indications
- Blurred vision
- Eye pain
- Double vision
- Frequent headaches
- History of eye disease in the family
- Changes in vision
- Redness or swelling of the eyes
Preparation
- Bring any current eyewear
- List of current medications
- Eye drops should be used as usual unless instructed otherwise
- Fasting is usually not required unless specified for specific tests
Procedure Description
- Patient History Review: The ophthalmologist will review medical history, family history of eye diseases, and any current symptoms.
- Visual Acuity Test: Assesses how well you can see at various distances.
- Eye Alignment and Movement Tests: Evaluates the alignment and movement of the eyes.
- Ocular Health Assessment: Involves examination of the external and internal parts of the eyes using various instruments like ophthalmoscope.
- Intraocular Pressure Measurement: Checks for glaucoma.
- Diagnostic Tests: Additional tests as needed based on initial findings.
Tools used include Snellen chart, ophthalmoscope, slit lamp, and tonometer. Typically, no anesthesia or sedation is required.
Duration
The initial exam can take between 1 to 2 hours, depending on the number of tests needed.
Setting
The procedure is performed in an ophthalmologist's office or an outpatient clinic.
Personnel
- Ophthalmologist
- Ophthalmic technician or nurse
Risks and Complications
- Mild discomfort from bright lights or eye drops
- Dilation effects like light sensitivity and blurred vision for a few hours Rare complications might include adverse reactions to diagnostic eye drops.
Benefits
- Early detection of vision problems and eye diseases
- Tailored treatment plans to preserve or improve vision
- Better eye health management and prevention of future issues
Recovery
- Minimal to no recovery time
- Patients might need someone to drive them home if eyes were dilated
- Follow-up visits as recommended for treatment or further evaluation
Alternatives
- Basic vision screening (less comprehensive)
- Optometric examination (conducted by an optometrist instead of an ophthalmologist)
Pros and cons: A comprehensive exam is more thorough compared to a basic vision screening, leading to earlier and more accurate diagnosis and treatment.
Patient Experience
Patients might feel mild discomfort due to bright lights or eye drops. Vision might be temporarily blurred if eyes are dilated. Pain management and comfort measures typically aren't necessary as the procedure is mostly non-invasive.