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  • Coding Competency Ask the Expert Exams Cataract/Anterior Segment

    Documentation Location for Activities of Daily Living


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    For cataract surgery, where do we document the patient’s specific activity of daily living (ADL) that is affected?

    Answer:
    There are several locations in the patient’s chart notes that auditors expect to see the activities of daily living documentation requirement: 
    • In the chief complaint supporting the reason for the examination
    • In the progress note  
    • In the operative report 
    If you document the activity on a separate form, such as a nationally recognized VF-8R, write it also in the patient’s chart so it is easily accessible in the event of an audit. Not all payers require a formal activity of daily living form, so always verify with each payer.

    Help us help you meet the documentation requirements for cataract surgery by visiting the Academy’s new Cataract Surgery Documentation hub.