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Detailed Posterior Exam for Macula and Vessels

Detailed Posterior Exam for Macula and Vessels

There are several optional detailed vessels and macula exams related to the Posterior exam that can be performed and documented on individual exam templates. These optional exam templates can be opened from the Posterior Exam Detail - OPH template or from the Physical Exam.

In the Macula section, you can document the following detailed exams:

AMD Detail – Age-related Macular Degeneration (AMD) Exam
VitreMac Detail – Vitreomacular Disorders
Histo Detail – Presumed Ocular Histoplasmosis Exam

In the Vessels section, you can document the following detailed exams:

BDR Detail – Background Diabetic Retinopathy (BDR) Exam
PDR Detail – Proliferative Diabetic Retinopathy (PDR) Exam
Vascular Detail – Vascular disorders

NextGen® Ophthalmic Suite Help 2022.2

Ophthalmology Drawings

Ophthalmic providers can create drawings to document exam findings. Links to the ophthalmic images appear at the bottom of the Provider - OPH template or can be accessed by clicking the Draw link. After the provider draws the exam findings, they are saved into the patient's chart and appear in the History Toolbar. The following images are available in the Ophthalmology specialty: Draw AC Draw Amsler Grid Draw Cornea Draw CVF Draw External Draw Face Draw Gaze Positions Draw Gonio Draw Lacrimal Draw Lens Draw Macula Draw Optic Nerve Draw Periphery Draw Pupil Draw Vitreous Draw Custom Draw Blank Page You can access the drawings in the Visual Acuity panel by clicking the Draw link. On the retina procedure templates, you can click the Draw button. The Draw button and link opens a list of different drawing backgrounds for Ophthalmology. Parent topic: Slit Lamp and Gonioscopy Exams

NextGen® Ophthalmic Suite Help 2022.2

Select the Ophthalmoscopy Exam Performed

You can select the type of extended ophthalmoscopy exam performed: Retinal Optic nerve or macula Only one of the ophthalmoscopy exams can be billed. On the Provider - OPH template, go to the Physical Exam panel. In the Ophthalmoscopy Exam section and do one of the following: To bill the retinal exam, select OD and/or OS for Bill retinal. To bill the optic nerve or macula exam, select OD and/or OS for Bill optic nerve or macula. Note: You cannot select both the Bill retinal and Bill optic nerve or macula. The corresponding billing code and modifier for the selected exam appear in the Procedure Billing panel on the Finalize - OPH template. Parent topic: Slit Lamp and Gonioscopy Exams

NextGen® Ophthalmic Suite Help 2022.2

Document a Posterior Exam

Ophthalmic providers can document Posterior exam findings in the Physical Exam panel. A more detailed Posterior exam can be documented on the Posterior Exam Detail template. You can document a posterior exam in the following areas. In the Physical Exam panel, navigate to the Posterior section. For a more detailed exam, click the Posterior link. Previosuly documented findings appear in the current encounter fields. Review and update the exam findings. To exclude an examination of the optic nerve: Select the Exclude check box in the Disc (ON) section. An Exclusions window appears. exclusions window Select an option in the Reason section. Select a specific reason from the list that appears, and click Save & Close. Data fields for Disc (ON) are hidden, and the selected reason for not performing an exam of the optic nerve appears. disc on section To save the documented values as the default values, click the Quick Save, and enter a name for the template. This feature enables you to use the

NextGen® Ophthalmic Suite Help 2022.2

Slit Lamp and Gonioscopy Exams

A Slit Lamp exam can be documented directly on the Physical Exam panel. A more detailed Slit Lamp exam can be documented on the Slit Lamp Exam Details - OPH template. Links to the Slit Lamp Exam Detail template appear in the External exam section of the Physical Exam panel and in the pane next to the physical exam grids. slit lamp exam details - oph template For providers, a link to the Gonioscopy – OPH exam template is also available. The detailed Gonioscopy exam is optional. Gonioscopy exam findings can be viewed or documented on the Gonioscopy – OPH template. Note: When you enter data on the Gonioscopy template, the system sends the Gonioscopy billing code to the Finalize - OPH tab where you can add a diagnosis code before submitting the code to the Superbill. Document a Gonioscopy Exam Ophthalmic providers can document the Gonioscopy exam on the Gonioscopy - OPH template. Document a Slit Lamp Exam Document a Posterior Exam Detailed Posterior Exam for Macula and Vessels Ophthalmolog

NextGen® Ophthalmic Suite Help 2022.2

Document a Detailed Ophthalmic Plan

You can document a detailed plan on the Oph - Plan Details template. On the Assessment/Plan - OPH template, in the Plan section, the OPH Plan link opens the Oph - Plan Details template. As you select details from different sections of the template, a summary statement appears in the Plan summary field. oph - plan details template Click the OPH Plan link to open the Oph - Plan Details template. Select the appropriate eye from the following: OD OS OU Select the appropriate check boxes in the following sections to document a detailed plan: General Discussions Medication Glasses/Contact Lenses Surgery Procedures Patient Instructions Tests Completed Today IOP Control In the Education Material section, select Education material provided and select the materials discussed with the patient. Note: Entering education material on the Oph-Plan Details template does not fulfill Quality Reporting requirements for patient education. To document follow-up details for the next visit, select the followi

NextGen® Ophthalmic Suite Help 2022.2

Information Documented on the Postoperative Exam Template

The Postoperative Exam - OPH template includes the following panels and sections: Panel/Section Description General Information section Review or document general information about the surgery, such as procedure and location, status post-procedure, days post-op, and surgeon Reason for Visit (with History of Present Illness) panel Review or document a reason for visit and HPI information for the encounter Visual Acuity exam panel Review or document visual acuity exam findings IOP exam panel Review or document visual acuity exam findings Examination section Review or document exam findings for External, Slit Lamp, and Posterior exams. Document intraocular lenses (IOL) that were implanted during cataract surgery Patient Instructions/Advice section Select advice and instructions for the patient Medications section Patient medications can be reviewed, reconciled, and documented. Internal Physician Notes section Providers use this section to keep historical notes that do not appear in genera