Document type: central, attic, marginal, total
Document laterality:Right, Left, Bilateral

Adult (main)|Pediatrics (main)

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• Document retained foreign objects in the eye: splinter, metal fragment, glass fragment
• Document location within the eye: cornea, conjuntiveal sac
• Document laterality: Right, Left, Bilateral
• Indicate the encounter type: Initial, Subsequent, Sequela

Adult (main)|Pediatrics (main)

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• Document type:
  • open angle, angle closure
  • pre-glaucoma/glaucoma suspect
  • subcapsular
  • Secondary to drugs
• Document stage:
  • mild stage
  • moderate stage
  • severe stage
  • indeterminate stage
  • unspecified

Adult (main)|Pediatrics (main)

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Adult (main)|Pediatrics (main)

Thanks to Advocate's Clinical Documentation Improvement and Coding teams for their assistance with this content.

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• Document diabetes type as: Type 1, Type 2, or Secondary
• Document nonproliferative diabetic retinopathy as:
  • Mild
  • Moderate
  • Severe
  • With or without macula edema
• If control is not maintained, document insulin control status as:
  • Inadequately controlled
  • Out of control
  • Poorly . . .

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Physician documentation must include the cause and effect relationship between the care provided and the condition that may be considered a complication.
Physician documentation must indicate that condition is a complication.
The physician may be asked for clarification if the complication is not clearly documented.

Adult . . .

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