Ophthalmology EHR, Practice Management, and Medical Billing Software
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Choosing an Ophthalmology EMR
What is Ophthalmology Software?
At the most basic level, ophthalmology software electronically stores patient medical information. Ideally, the software not only takes into account all the unique needs of ophthalmology practices, it also helps ophthalmologists spend more time with patients. But no matter how modern or feature-filled an electronic medical record (EMR) is, unless it easily integrates with all other software used in the ophthalmology practice—everything from medical devices to billing software—it’s not a good choice.
Tomorrow’s Software Today
Today’s patients expect simple, fast, multi-channel communication with all their providers, along with virtual visits when appropriate. To keep up, ophthalmology practices must provide secure text and chat for appointment making, automated appointment reminders, electronic registration, mobile check-in, and automated e-billing and statements.
How Can Modern Ophthalmology Software Benefit Physicians?
- Simplify workflow. Ophthalmology patients begin with booking an appointment, having an exam, and either scheduling more tests or receiving a diagnosis. From there, they may need to order corrective lenses or schedule surgery, and they will likely need one or more follow-up visits. EMRs help streamline these processes to ease the administrative burden on the ophthalmologist and his/her staff.
- Simplify documentation. Many ophthalmologists are afraid an EMR will take away from the personalized nature of their patient visits. The truth is, EMRs are no more intrusive than filling out a paper chart, can accommodate the use of a scribe, and can speed up the process of viewing old records. Look for an EMR that includes templates for notes regarding cataracts, blurred vision, glaucoma, mascular degeneration, chalazion, corneal abrasion, ectropion, entropion, and Graves’ Disease.
- Simplify coding. Coding is complex and likely to become more so. Ophthalmologists need software that improves efficiency by quickly leading them through the process to enter, for example, a type of ophthalmic ultrasound or an eye disease category.
What’s the Biggest Mistake Ophthalmologists Make When Choosing an EMR?
No matter how modern or feature-filled an EMR is, unless it easily integrates with all other software used in the ophthalmology practice—everything from exam devices to billing software—it’s not a good choice.
Put simply, the ophthalmology EMR you select should help providers:
- Provide in-office and remote patient care
- Quickly create superbills
- Easily track revenue to avoid leaks
- Create customized notetaking templates
- Create dashboards to track patient progress
- Easily gather data from devices such as autorefractors and keratometers
Lastly, an ophthalmology EMR should be able to quickly integrate with patient-facing systems such as patient portals and personal electronic medical records.
- “What is Ophthalmology Software?” Software Advice, accessed 20 September 2021. https://www.softwareadvice.com/medical/ophthalmology-software-comparison/#buyers-guide
- Archibald, Christine. “8 Popular EHR Myths Debunked.” February 2015. https://crstoday.com/articles/2015-feb/8-popular-ehr-myths-debunked/
- Parker, Emiley. “Ophthalmology EMR Software Buyer’s Guide 2021.” 14 September 2021. https://www.emrsystems.net/ophthalmology-emr/
ICD-10 Ophthalmology Superbill Example
|Appointment Date & Time:||Last Seen Date:|
|Patient:||Gender:||DOB:||MR#||Pat Due:||INS Due:|
|Home Phone:||Cell Phone:||E-Mail:|
|Case Name:||Case No:||Case Type:||Case Date:|
|Pr Insurance:||Member ID:||Co-Pay Amount:||Deductible:|
|Rendering Provider:||PCP:||Referring Provider:|
|CPT Code||Description||CPT Code||Description||CPT Code||Description|
|92004||Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; comprehensive, new patient, one or more visits||92002||Ophthalmological services; medical examination and evaluation with initiation of diagnostic and treatment program; intermediate, new patient||92140||Provocative tests for glaucoma, with medical diagnostic evaluation, without tonography|
|92014||Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive, established patient, one or more visits||D 92004||Comprehensive, new patient, one or more visits||D 92225||Ophthalmoscopy, extended as for retinal detachment (may include use of contact lens, drawing or sketch, and/or fundus biomicroscopy), with medical diagnostic evaluation; initial|
|99204 – 99205||Office or other outpatient visit for the evaluation and management of a new patient||92012||Ophthalmological services; medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established patient.||D 92226 x||With ophthalmodynamometry|
|99214 – 99215||Office or other outpatient visit for the evaluation and management of an established patient; moderate to high complexity||D 92014||Comprehensive, established patient, One or more visits||D 92250||With fundus photography|
|99244 – 99245||Office consultation for a new or established patient; moderate to high severity; 60-80 minutes||D 92020||Conioscopy with medical diagnostic evaluation (separate procedure).||D 92260||With ophthalmodynamometry|
|92250||Fundus Photography||92060||Sensorimotor examination with medical diagnostic evaluation (separate procedure).||92270||Electro-oculography, with medical diagnostic evaluation|
|76510||Ophthalmic ultrasound, diagnostic; B-scan and quantitative A-scan performed during the same patient encounter||92065||Orthoptic and/or pleoptic training, with continuing medical direction and evaluation||D 92275||Electroretinography, with medical diagnostic evaluation|
|76511||Ophthalmic ultrasound, diagnostic, A-scan only||T 92070||Fitting of contact lens for treatment of disease, including supply of lens||92280||Visually evoked potential (response) study, with medical diagnostic evaluation|
|76512||Ophthalmic ultrasound, diagnostic, contact B-scan (with or without A scan)||92081||Visual field examination with medical diagnostic evaluation; tangent screen; autoplot or equivalent||92283||Color vision examination, extended, e.g., anomaloscope or equivalent|
|76513||Ophthalmic ultrasound, diagnostic, immersion (water bath) B-scan||92082||Quantitative perimetry, e.g., several isopters on Goldmann perimeter, or equivalent||92284||Dark adaptation examination, with medical diagnostic evaluation|
|76514||Ophthalmic ultrasound, corneal pachymetry||92083||Static and kinetic perimetry, or equivalent||92285||External ocular photography for documentation of medical progress|
|76516||Ophthalmic biometry by ultrasound, A-scan||92100||Serial tonometry with medical diagnostic evaluation (separate procedure), one or more sessions, same day||92286||Specular endothelial microscopy with photographic documentation, medical evaluation and report|
|76519||Ophthalmic biometry by ultrasound, A-scan w/intraocular lens power calculation||D 92120||Tonography with medical diagnostic evaluation, recording indentation tonometer method or perilimbal suction method||65205||Removal of foreign body, external eye; conjunctival superficial|
|76529||Echo exam of eye for foreign body||D 92130||Tonography with water provocation||67820||Correction trichiasis; epilation, forceps only|
|H52.00||Hypermetropia, unspecified eye||H52.513||Internal ophthalmoplegia (complete) (total), bilateral||D23.10-D23.12||Other benign neoplasm of skin of eyelid, including canthus|
|H52.01||Hypermetropia, right eye||H52.519||Internal ophthalmoplegia (complete) (total), unspecified eye||D31.00-D31.92||Benign neoplasm of eye and adnexa|
|H52.02||Hypermetropia, left eye||H52.521||Paresis of accommodation, right eye||E08.00-E13.9||Diabetes mellitus|
|H52.03||Hypermetropia, bilateral||H52.522||Paresis of accommodation, left eye||G35||Multiple sclerosis|
|H52.10||Myopia, unspecified eye||H52.523||Paresis of accommodation, bilateral||G45.3||Amaurosis fugax|
|H52.11||Myopia, right eye||H52.529||Paresis of accommodation, unspecified eye||G93.0-G93.2||Other disorders of brain|
|H52.12||Myopia, left eye||H52.531||Spasm of accommodation, right eye||H01.001-H02.9||Other inflammation of eyelid|
|H52.13||Myopia, bilateral||H52.532||Spasm of accommodation, left eye||H15.001- H43.9||Disorders of sclera|
|H52.201||Unspecified astigmatism, right eye||H52.533||Spasm of accommodation, bilateral||H44.121- H44.129||Parasitic endophthalmitis, unspecified|
|H52.202||Unspecified astigmatism, left eye||H52.539||Spasm of accommodation, unspecified eye||H44.50- H44.539||Degenerated conditions of globe|
|H52.203||Unspecified astigmatism, bilateral||H52.6||Other disorders of refraction||H44.811- H49.9||Other disorders of globe|
|H52.209||Unspecified astigmatism, unspecified eye||H52.7||Unspecified disorder of refraction||H50.21- H51.9||Vertical strabismus|
|H52.211||Irregular astigmatism, right eye||H53.71||Glare sensitivity||H53.10- H53.489||Subjective visual disturbances|
|H52.212||Irregular astigmatism, left eye||H53.72||Impaired contrast sensitivity||H53.60- H53.69||Night blindness|
|H52.213||Irregular astigmatism, bilateral||H53.8||Other visual disturbances||H54.0- H57.9||Blindness|
|H52.219||Irregular astigmatism, unspecified eye||H53.9||Unspecified visual disturbance||H59.40- H59.43||Inflammation (infection) of postprocedural bleb|
|H52.221||Regular astigmatism, right eye||Z01.00||Encounter for examination of eyes and vision without abnormal findings||Q10.0- Q15.9||Congenital malformations of eyelid, lacrimal apparatus and orbit|
|H52.222||Regular astigmatism, left eye||Z01.01||Encounter for examination of eyes and vision with abnormal findings||R44.1||Visual hallucinations|
|H52.223||Regular astigmatism, bilateral||A18.50-A18.59||Tuberculosis of eye||S00.10XA- S00.279S||Contusion of eyelid and periocular area|
|H52.229||Regular astigmatism, unspecified eye||A74.0||Chlamydial conjunctivitis||S05.00XA- S05.12XS||Injury of conjunctiva and corneal abrasion without foreign body|
|H52.31||Anisometropia||B30.0-B30.9||Viral conjunctivitis||S05.8X1A-S05.92XS||Other injuries of right eye and orbit|
|H52.32||Aniseikonia||B39.4-B39.9||Histoplasmosis||T15.00XA- T15.92XS||Foreign body in cornea|
|H52.4||Presbyopia||B60.13||Keratoconjunctivitis due to Acanthamoeba||T85.310A- T85.398S||Breakdown (mechanical) of prosthetic orbit of right eye|
|H52.511||Internal ophthalmoplegia (complete) (total), right eye||C44.101-C44.199||Other and unspecified malignant neoplasm of skin of eyelid, including canthus||T86.840- T86.849||Corneal transplant rejection|
|H52.512||Internal ophthalmoplegia (complete) (total), left eye||D22.10-D22.12||Melanocytic nevi of eyelid, including canthus||H53.001- H53.039||Amblyopia|