NYOPH Surgery Booking form
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.
Email *
Urgency *
Surgeon *
Patient Name *
Patient DOB *
MM
/
DD
/
YYYY
Patient MRN *
Laterality
Clear selection
ASC desired (optional)
Premium Cataract Surgery
CPT (Cataract & Anterior Segment)
CPT (Glaucoma and Laser)
CPTs (Retinal AND Laser)
CPTs (Oculoplastics)
ICDs (Diagnosis) *
Required
ICDs (Glaucoma)
OD
OS
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)
R
L
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)
Notes (if any)