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Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established patient

CPT4 code

Name of the Procedure:

Ophthalmological Services: Medical Examination and Evaluation, with Initiation or Continuation of Diagnostic and Treatment Program; Intermediate, Established Patient

Summary

This procedure involves a thorough eye examination and medical evaluation aimed at diagnosing and managing eye health problems in patients who have previously been seen by the healthcare provider. It includes starting or continuing any necessary diagnostic tests and treatments.

Purpose

  • Medical Condition: Addresses various eye health issues like glaucoma, cataracts, macular degeneration, and diabetic retinopathy.
  • Goals/Outcomes: To monitor eye health, diagnose any conditions, and adjust treatment plans to maintain or improve vision and eye health.

Indications

  • Symptoms/Conditions: Patients experiencing changes in vision, discomfort, redness, or those with ongoing conditions like diabetes or hypertension that affect eye health.
  • Patient Criteria: Established patients needing follow-ups or ongoing management of diagnosed eye conditions.

Preparation

  • Pre-Procedure Instructions: Avoid wearing eye makeup and contact lenses. Bring current prescriptions for glasses or sunglasses.
  • Diagnostic Tests: May include previous vision tests, photos of the eye, pressure measurements, and a review of medical history.

Procedure Description

  1. Visual Acuity Test: Measures the sharpness of vision.
  2. Slit Lamp Examination: Uses a microscope to examine the structures of the eye.
  3. Tonometry: Checks the pressure inside the eye.
  4. Retinal Examination: Depending on the condition, may involve dilating the pupils to examine the retina.
  5. Initiation or Adjustment of Treatment Plan: Could involve prescribing medication, scheduling further tests, or planning surgical intervention if necessary.

Duration

Typically takes about 30-45 minutes.

Setting

Performed in an outpatient clinic or specialized ophthalmology office.

Personnel

  • Healthcare Professionals: Ophthalmologist or optometrist, and trained ophthalmic assistants or technicians.

Risks and Complications

  • Common Risks: Temporary discomfort from eye drops, temporary blurred vision from pupil dilation.
  • Rare Risks: Allergic reaction to eye drops, infection, or improper diagnosis if the condition is not fully understood.

Benefits

  • Expected Benefits: Accurate diagnosis and effective management of eye conditions, potentially preventing vision loss and maintaining overall eye health.
  • Realization: Benefits are usually observed immediately with appropriate management and follow-up care.

Recovery

  • Post-Procedure Care: Avoid rubbing the eyes, and use prescribed eye drops if necessary.
  • Recovery Time: Immediate recovery with no downtime; may experience temporary blurred vision from dilation.
  • Restrictions/Follow-Up: Regular follow-up appointments as recommended by the healthcare provider.

Alternatives

  • Other Options: Telehealth consultations, optometrist evaluations for milder issues.
  • Pros and Cons: Optometrist evaluations may be less comprehensive. Telehealth lacks hands-on examination, which is crucial for intricate eye conditions.

Patient Experience

  • During the Procedure: Minimal discomfort, possible brief stinging from eye drops.
  • After the Procedure: Temporary blurred vision from dilation, which improves within a few hours. Prompt communication regarding results and ongoing treatment plans is essential for patient reassurance.

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