NYOPH Surgery Booking form

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If you have a preference of a surgery center, please indicate so. The surgery department will contact the PCP of the patient as indicated in our EMR to set up a Pre Admission Test Date (clearance). Please ensure that we have the correct PCP information in our EMR.

Urgency *

Surgeon *

Patient Name *

Patient DOB *

YYYY

Patient MRN *

Laterality *

OD (Right)

OS (Left)

OU / OD first

OU / OS first

LUL (E1)

LLL (E2)

RUL (E3)

RLL (E4)

ASC desired (optional)

Premium Cataract Surgery

FEMTO

MULTIFOCAL

TORIC

ORA

CPT (Cataract & Anterior Segment)

66982 Cataract Excision w/IOL (complex)

66984 Cataract Excision w/IOL (simple)

66987 ECP & CE/IOL (standard)

66988 ECP & CE/IOL (complex)

65782 Ocular Surface Reconstruction with conjunctival autograft

65780 Ocular Surface Reconstruction with amniotic membrane

65875 Severing Posterior Synechiae. Iris to Lens Capsule or to Vitreous Body severed

65880 Severing Corneovitreal Adhesions

CPT (Glaucoma and Laser)

0191T Hydrus

0191T iStent

0376T iStent Inject (each additional)

65800 Paracentesis

65820 Goniotomy (Kahook)

65820 Goniotomy (OMNI)

66174 Canaloplasty (OMNI)

66180 Aqueous Shunt (Ahmed)

66180 Aqueous Shunt (Baerveldt)

66180 Aqueous Shunt (ClearPath)

66711 ECP (no phaco)

66183 Insertion of A/S Drain (XEN) w MMC

66185 Revision of Tube (Trim)

66185 Revision of Tube (Erosion)

66185 Revision of Tube (Reposition)

65426 Pterygium

65855 SLT

66761 YAG PI

66762 Iridoplasty

66710 TSCPC

66821 YAG Cap

CPTs (Retinal AND Laser)

65235 Removal of FB. Intraocular; Anterior Chamber of Eye or Lens

65260 Removal of FB. Intraocular; Posterior Segm. Magnetic Extraction

65265 Removal of FB. Intraocular; Posterior Segm. Non- Magnetic Extraction

65920 Remove IMPLANTED Material (IOL). Anterior Segm. (not replaced. If replaced use code 66986)

65920 Removal of IOL w/o secondary Implantation (s)

66825 Reposition intraocular Lens Prosthesis

66850 Removal Lens Material Phaco Frag. No Lens inserted

66852 Removal Cataract Obstructing the View During Surgery w or w/o P/P Vitrectomy

66985 Secondary IOL Implant

66986 Exchange of intraocular Lens

67005 Anterior Vitrectomy Partial

67036 PPV

67039 PPV w/ Focal Endolaser photocoagulation

67040 PPV w/Endolaser Panretinal Photocoagulation

67041 PPV for Macular Pucker

67042 PPV w/Removal Internal Limiting Membrane (Macular Hole. Diabetic Macular Edema)

67107 Repair Retinal Detach. Scleral Buckling

67108 Repair Retinal Detach. w/Vitrectomy

67113 Complex Retinal Detach. w/Vitrectomy and Membrane Peel

67120 Remove IMPLANTED Material Posterior Segm. Extraocular

67120 Remove IMPLANTED Material Posterior Segm

67121 Removal of IMPLANTED Material. Posterior Segm. Intraocular (e.g. Removal of IOL. Fallen into Posterior Segm. P/P Approach)

92018 Exam Under General Anesthesia. Complex

67820 Intravitreal Injection

CPTs (Oculoplastics)

15823 Blepharoplasty

67900 Brow Lift

67908 Ptosis Conj Muller

67904 Ptosis ELR

67917 Ectropion

14060 SOOF Lift/ Adjacent Tissue TX

15260 Full Thickness Skin Graft

68440 Punctoplasty

67917 Entropion

67923 Entropion

67924 Entropion

68720 Ext DCR

31239 Endo DCR

68815 NLDI

67966 Full Thickness Excision

67961 Full Thickness Excision

67412 Orbit Lesion Excision

67800 I+D Stye

67801 I+D Stye

67805 I+D Stye

67808 I+D Stye

67700 I+D Stye

67840 Lesion Excision

68110 Lesion Excision Conj

67825 Electroepilation

ICDs (Diagnosis) *

H25.11/H25.12 Cataract Nuclear

H25.019 Senile Cataract Corlcal

H25.049 Senile Cataract. Post Subcapsular

H25.89 Senile Cataract. Total or Mature

H11.009 Pterygium

H11.053 Peripheral Progressive pterygium

H11.069 Recurrent Pterygium

H21.03 Hyphema

H21.54 Posterior Synechiae

H21.51 Anterior Synechiae

H21.52 Goniosynechiae

H40.11X Primary open angle Glaucoma

H40.13 Pigmentary Glaucoma

H40.21 Acute Angle Glaucoma

H40.23 Intermittent Angle Glaucoma

H40.22 Chronic Angle closure Glaucoma

H21.0 Hyphema

H21.1x Other vascular disorders of Iris/CB

H21.50 Unspecified Adhesions & Disruptions of Iris/CB

H26.41 Secondary Cataract, Soemmering's

H26.49 Other Secondary Cataract

H27.03 Aphakia

H27.139 Posterior Dislocation of Lens

H33.019 Retinal Detach. Partial. Single Defect

H33.029 Retinal Detach. Partial Multiple Defects

H33.039 Retinal Detach. Recent. Partial w/Gian Tear

H33.059 Retinal Detach. Recent. Total or Subtotal

H33.43 Detachment of Retina. Tractional

H34.8110 Central Retinal vein Occlusion

H35.23 Other Non-Diabetic Proliferative Retinopathy

E11.311/E113591 Diabetic Retinopathy.Proliferative

H35.349 Macular Cyst.Hole Psuedohole

H35.379 Macular Puckering

H40.22 CACG

H43.03 Vitreous Prolapse

H43.13 Vitreous Hemorrhage

H43.319 Vitreous Membranes/Strands

H43.399 Vitreous Opacities. Floaters

H44.659 Retained (old) FB; Magnetic

H44.759 Retained (old) FB; NonMagnetic

H57.03 Pupil Miosis. Persistent

Other:

Required

ICDs (Glaucoma)

Unspec

Mld

Mod

Sev

Int

H25.1X Cataract, age-related, nuclear sclerotic

H25.0X Cataract, age-related, cortical

H40.10x Unspecified OAGL

H40.11x Primary OAGL

H40.13 Pigmentary Glaucoma

H40.21 Acute angle glaucoma

H40.22 Chronic angle closure glaucoma

H40.23 Intermittent angle glaucoma

H43.31 Vitreous membranes and strands

H43.39 Vitreous Opacities

H43.81 Vitreous degeneration

H43.82 Vitreomacular Adhesions

H21.0 Hyphema

H21.1x Other vascular disorders of Iris/ciliary body

H21.50 Unspec. Adhesions and disruptions Iris/c.b.

H21.51 Anterior Synechiae

H21.52 Goniosynechiae

H26.41 Secondary Cataract, Soemmering's

H26.49 Other Secondary Cataract

H35.05 Retinal neovascularization, unspecified

H35.71 Central serous chorioretinopathy

H40.01 Open Angle w/Borderline findings low risk

H40.02 OAGL w/Boderline findings high risk

H40.03 Anatomical narrow angle

Unspec

Mld

Mod

Sev

Int

H25.1X Cataract, age-related, nuclear sclerotic

H25.0X Cataract, age-related, cortical

H40.10x Unspecified OAGL

H40.11x Primary OAGL

H40.13 Pigmentary Glaucoma

H40.21 Acute angle glaucoma

H40.22 Chronic angle closure glaucoma

H40.23 Intermittent angle glaucoma

H43.31 Vitreous membranes and strands

H43.39 Vitreous Opacities

H43.81 Vitreous degeneration

H43.82 Vitreomacular Adhesions

H21.0 Hyphema

H21.1x Other vascular disorders of Iris/ciliary body

H21.50 Unspec. Adhesions and disruptions Iris/c.b.

H21.51 Anterior Synechiae

H21.52 Goniosynechiae

H26.41 Secondary Cataract, Soemmering's

H26.49 Other Secondary Cataract

H35.05 Retinal neovascularization, unspecified

H35.71 Central serous chorioretinopathy

H40.01 Open Angle w/Borderline findings low risk

H40.02 OAGL w/Boderline findings high risk

H40.03 Anatomical narrow angle

ICD (Oculoplastics)

RUL

RLL

LUL

LLL

H02.83 Dermatochalasis

H57.81 Brow Ptosis

Q10.0 Congenital Ptosis

Q10.3 Epibleph / Congentital Malf. Lid

H02.13 Senile Ectropion

H02.11 Cicatricial Ectripion

H04.56 Punctal Stenosis

H02.03 Senile Entropion

H04.55 Nasolacrimal Obst

H04.53 Congenital NLDO

D23.1 Neoplasm

C44.1 BCC

D48.1 Neopl. Uncertain

D31.0 Benign Conj. Lesion

D31.6 Benign Orbit Lesion

H00.1 Chalazion

H00.03 Abscess

H02.05 Trichiasis

Medications (if any)

Avastin

Trimoxi

Dexycu

Omidria

Trypan

Dextenza

Patient Age

Visual Acuity

IOP

Medications

Important Comorbidities

Notes (if any)

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