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  • Ask the Expert Cataract/Anterior Segment

    Complex Cataract Operative Report


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    Our ambulatory surgery center has an operative report template with the option to check a box at the end of the report if trypan, capsular tension ring or iris hooks were used during the case, making it complex. Is it sufficient to check the appropriate box or does it also need to be embedded in the operative report as well?

    Answer:
    Check boxes are not sufficient. There must also be a narrative for the operative report. The Academy has received reports of audits failing due to check box operative reports lacking any narrative of what happened during the surgery. You must also document the reason for needing to use additional equipment in the supporting diagnosis. 

    See Cataract Surgeries Can Be Complex, Coding Doesn’t Have to Be.