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.
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NextGen® Ophthalmic Suite Help 2022.2
Document a Gonioscopy Exam
Note: When you document your exam on the Gonioscopy template, the Gonioscopy code appears in the Procedure Billing grid on the Finalize - OPH template. You must add a diagnosis code to the procedure code prior to submitting the code to the Superbill. Click the Gonio Exam link to open the Gonioscopy - OPH template. gonioscopy - oph template To use copied-forward exam findings from the last documented exam, select the Copy last exam check boxes for OD and OS. Note: You must have privileges to use copy-forward. Each practice can configure provider privileges for exam copy-forward on the Eye Configuration practice template. For more information, go to NextGen Healthcare Success Community and download the latest Setup Guide for NextGen® Ophthalmic Suite. For each eye, document up to four findings, each with one modifier. For each eye, document values for Sup (Superior), Temp (Temporal), Nas (Nasal), and Inf (Inferior) by clicking the fields and selecting one or more values from lists, then
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
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 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
Gonioscopy Exam
The detailed Gonioscopy exam is optional. Gonioscopy exam findings can be viewed or documented on the Gonioscopy – OPH template, which can be opened from three different places: Slit Lamp Exam Detail template - during technician/assistant and provider workflow Provider – OPH template – on the Physical Exam panel during provider workflow OPH Physical Eye Exam template – during provider workflow Note: When you make an entry on the Gonioscopy - OPH template causes Gonioscopy to appear in the list of billable procedures on the Finalize - OPH template. You must add a diagnosis code to the Gonioscopy procedure on the Finalize - OPH template. Parent topic: Physical Exams (Technicians/Assistants)
