Wiki 66984

Not sure I understand what you are asking for. My assumption is that an auditor would look at the informed consents, any paperwork involving the patient selecting a premium IOL which would require additional out of pocket payment, plus any records written at the pre op exam where the decision for surgery was made as well as good operative notes and any records from post of visits.

If a patient is comanaged by another doctor for post op care, then you need a consent signed by the patient agreeing to the comanagement, in addition to the regular surgery consent. You also need to have a form signed by the surgeon noting the date he relinquished care to the comanaging doctor plus copies of the records the comanaging doctor sent back to the surgeon which were generated at those post op visits.

There may be a couple of other things, but those are the major ones.

Tom Cheezum, OD, CPC, COPC
 
You might also look to see if there is quality of life questionnaire in the chart - many payers (esp. Medicare) are looking for this documentation.

David E. Keown, CPC, OCS
 
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