MAY 07, 2024
Where Should Devices Used in Complex Cataract Surgery be Documented?
Does the cataract surgery operative report need to include that trypan blue was injected, or iris hooks were used during the surgical process or can there just be a note/section at the bottom of the operative note indicating trypan blue or hooks were used?
Answer:
The operative report should include all work performed and the devices that were utilized. When techniques and devices not typically used in standard cataract surgery are employed the documentation must support what was used and why they were used. The why also requires the appropriate diagnosis, code such as mature cataract with use of trypan blue dye or a miotic pupil that will not dilate sufficiently requiring iris hooks.
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