• Exam Prior to YAG

    Question: Is it required that the surgeon perform a complete dilated exam prior to scheduling a procedure such as a YAG capsulotomy? I have heard that the referring physician can schedule the patient for a procedure without the surgeon seeing the patient first.

    Answer: There are two issues here. First: It is standard of care for the surgeon to see the patient before surgery, and any decision for surgery be made between the patient and the surgeon. The surgeon must provide the risks and benefits and obtain the informed consent. Second: Whether the patient is dilated or not is also at the surgeon’s discretion.

    Learn more about surgical requirements in Ophthalmic Coding: Learn to Code Cataract and Anterior Segment.