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Documentation for “Second” Eye Surgeries – Ophthalmic Professional

Most of us know how to properly document the functional complaints that justify the medical necessity for cataract and YAG capsulotomy. The same level of documentation applies to each eye. While that seems straightforward, patients may inadvertently not properly justify the need for the second eye surgery.

Topics addressed in this article include:

  • Improper documentation
  • Necessity for justification of each eye
  • The need to double check your notes

This article was published in Ophthalmic Professional’s Coding column, and written by Corcoran’s Senior Consultant, Paul Larson, COE. To view the entire article in Ophthalmic Professional, click on the link below:


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