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Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Order Sets,Ambulatory,Madison Surgery Center

MSC - Opthalmology/Cataract - Adult - Pre/Intraoperative [4966]

MSC - Opthalmology/Cataract - Adult - Pre/Intraoperative [4966] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Ambulatory, Madison Surgery Center


MSC - Opthalmology/Cataract - Adult - Pre/Intraoperative [4966]
Pre-op Day of Procedure
Vital Signs [132642]
Vital Signs [NURMON0013] ONCE For 1 Occurrences, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Pre-Op Day Of Procedure
Patient Care Orders [136623]
Consent [NURCOM0022] ONCE, Starting today For 1 Occurrences, Consent to read:
***, Pre-Op Day Of Procedure
No Pre-op Day of Surgery Orders Needed
[NURCOM0022]
ONCE, Pre-Op Day Of Procedure
IV Fluids [132631]
Insert and Maintain Peripheral IV [NURVAD0013] CONTINUOUS, Routine
Peripheral IV Size: RN Discretion
Does this need to be inserted/placed?
Pre-Op Day Of Procedure
lactated ringers infusion [38890] at 75 mL/hr, Intravenous, CONTINUOUS, Pre-Op Day Of
Procedure
sodium chloride 0.9 % infusion [64367] at 75 mL/hr, Intravenous, CONTINUOUS, Pre-Op Day Of
Procedure
Premedications for Needle Insertion [135577]
Use lidocaine topical dressing kit for stable patient, no lidocaine allergies, have at least 30 minutes time prior to needing
to use IV
Sodium chloride (bacteriostatic) 0.9% intradermal: Useful for patients requiring urgent IV access; onset is within 1 minute.
Choice of medication should be based on patient’s previous experience/preference, history of lidocaine allergy and ease
of access.
lidocaine 1 % vial [39034] 0.1-0.4 mL, Intradermal, PRN, peripheral line insertion - see
Admin Instructions
Use an insulin or TB syringe with a 25-30 gauge needle to
inject solution and create a wheal. Wait 30 seconds to 1
minute then insert IV catheter into center of wheal. Use if IV
is needed within 30 minutes. Choice of medication should be
based on patient’s previous experience/preference, history of
lidocaine allergy and ease of access
Pre-Op Day Of Procedure
sodium chloride (bacteriostatic) 0.9 % injection [50585] 0.05-0.1 mL, Intradermal, PRN, peripheral line insertion - see
Admin Instructions
Use an insulin or TB syringe with a 25-30 gauge needle to
inject solution and create a wheal. Wait 30 seconds to 1
minute then insert IV catheter into center of wheal. Use if IV
is needed within 30 minutes. Choice of medication should be
based on patient’s previous experience/preference, history of
lidocaine allergy and ease of access
Pre-Op Day Of Procedure
Premedications [132961]
diazepam (VALIUM) tab [36679] 5 mg, Oral, ONCE PRN For 1 Doses, anxiety
Give 60 minutes pre-operatively as needed
Pre-Op Day Of Procedure
Medications - Non-Categorized [132969]
mitomycin (MUTAMYCIN) in water (sterile) 1 mL
ophthalmic injection [700539]
0.4 mg, Intraocular, ONCE For 1 Doses, IntraOp
Medications - RIGHT EYE [132971]
Page 1 of 5
Printed by GUETZLAFF, SCOTT F [SFG091] at 1/14/2016 2:10:35 PM

Copyright © 2015 University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:



















 
01/2016Lee Vermeulen, CCKM@uwhealth.org

pre-op dilating drops (lidocaine jelly 2%,
phenylEPHRINE 2.5%, tropicamide 1%, cyclopentolate
2%, moxifloxacin 0.5%, flurbiprofen 0.03%) [785146]
1 drop, Eye (Right), EVERY 5 MINUTES For 3 Doses
Administer 45 minutes prior to surgery
Pre-Op Day Of Procedure
cyclopentolate (CYCLODRYL) 1 % ophthalmic soln
[36271]
1 drop, Eye (Right), EVERY 5 MINUTES For 4 Doses, Pre-
Op Day Of Procedure
diclofenac (VOLTAREN) 0.1 % ophthalmic soln [44946] 1 drop, Eye (Right), EVERY 5 MINUTES For 4 Doses, Pre-
Op Day Of Procedure
flurbiprofen (OCUFEN) 0.03 % ophthalmic soln [45205] 1 drop, Eye (Right), EVERY 5 MINUTES For 4 Doses, Pre-
Op Day Of Procedure
ofloxacin (OCUFLOX) 0.3 % ophthalmic soln [55774] 1 drop, Eye (Right), EVERY 5 MINUTES For 3 Doses
May use patient's own supply
Pre-Op Day Of Procedure
phenylEPHRINE 2.5 % ophthalmic soln [41006] 1 drop, Eye (Right), EVERY 5 MINUTES For 4 Doses, Pre-
Op Day Of Procedure
pilocarpine (PILOCAR) 2 % ophthalmic soln [41044] 1 drop, Eye (Right), ONCE For 1 Doses, Pre-Op Day Of
Procedure
polymyxin-trimethoprim (POLYTRIM) 10000-0.1
UNIT/ML-% ophthalmic soln [46801]
1 drop, Eye (Right), EVERY 5 MINUTES For 3 Doses
May use patients own supply
Pre-Op Day Of Procedure
prednisolone (PRED FORTE) 1 % ophthalmic susp
[41271]
1 drop, Eye (Right), EVERY 5 MINUTES For 3 Doses
May use patient's own supply
Pre-Op Day Of Procedure
tetracaine 0.5 % ophthalmic soln [42707] 1 drop, Eye (Right), ONCE For 1 Doses
To be given just before any other eye drops
Pre-Op Day Of Procedure
tropicamide (MYDRIACYL) 1 % ophthalmic soln [43208] 1 drop, Eye (Right), EVERY 5 MINUTES For 4 Doses, Pre-
Op Day Of Procedure
Medications - RIGHT EYE - Non Formulary (Must Be Supplied By Patient) [135526]
bromfenac (XIBROM) 0.09 % ophthalmic soln NF
[107676]
Eye (Right)
Must use patient's own supply
Pre-Op Day Of Procedure
ketOROLAC (ACULAR) 0.5 % ophthalmic soln NF
[55760]
1 drop, Eye (Right), EVERY 5 MINUTES For 4 Doses
Must use patient's own supply
Pre-Op Day Of Procedure
moxifloxacin (VIGAMOX) 0.5 % ophthalmic soln NF
[72666]
Eye (Right)
Must use patient's own supply
Pre-Op Day Of Procedure
nepafenac (NEVANAC) 0.1 % ophthalmic soln NF
[109336]
Eye (Right)
Must use patient's own supply
Pre-Op Day Of Procedure
Medications - RIGHT EYE - Miscellaneous [135536]
phenylEPHRINE 10 % ophthalmic soln [41005] 1 drop, Eye (Right), ONCE PRN Starting today For 1 Doses,
Pupil does not dilate to 7-8mm after pre-op drops
If the patient's pupil does not dilate to 7-8 mm after pre-op
drops, give one drop in RIGHT EYE.
Blood pressure must be less than or equal to 160/90.
Pre-Op Day Of Procedure
Medications - LEFT EYE [132970]
pre-op dilating drops (lidocaine jelly 2%,
phenylEPHRINE 2.5%, tropicamide 1%, cyclopentolate
2%, moxifloxacin 0.5%, flurbiprofen 0.03%) [785146]
1 drop, Eye (Left), EVERY 5 MINUTES For 3 Doses
Administer 45 minutes prior to surgery
Pre-Op Day Of Procedure
cyclopentolate (CYCLODRYL) 1 % ophthalmic soln
[36271]
1 drop, Eye (Left), EVERY 5 MINUTES For 4 Doses, Pre-Op
Day Of Procedure
diclofenac (VOLTAREN) 0.1 % ophthalmic soln [44946] 1 drop, Eye (Left), EVERY 5 MINUTES For 4 Doses, Pre-Op
Day Of Procedure
flurbiprofen (OCUFEN) 0.03 % ophthalmic soln [45205] 1 drop, Eye (Left), EVERY 5 MINUTES For 4 Doses, Pre-Op
Day Of Procedure
ofloxacin (OCUFLOX) 0.3 % ophthalmic soln [55774] 1 drop, Eye (Left), EVERY 5 MINUTES For 3 Doses
May use patient's own supply
Page 2 of 5
Printed by GUETZLAFF, SCOTT F [SFG091] at 1/14/2016 2:10:35 PM

Copyright © 2015 University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:



















 
01/2016Lee Vermeulen, CCKM@uwhealth.org

Pre-Op Day Of Procedure
phenylEPHRINE 2.5 % ophthalmic soln [41006] 1 drop, Eye (Left), EVERY 5 MINUTES For 4 Doses, Pre-Op
Day Of Procedure
prednisolone (PRED FORTE) 1 % ophthalmic susp
[41271]
1 drop, Eye (Left), EVERY 5 MINUTES For 3 Doses
May use patient's own supply
Pre-Op Day Of Procedure
pilocarpine (PILOCAR) 2 % ophthalmic soln [41044] 1 drop, Eye (Left), ONCE For 1 Doses, Pre-Op Day Of
Procedure
polymyxin-trimethoprim (POLYTRIM) 10000-0.1
UNIT/ML-% ophthalmic soln [46801]
1 drop, Eye (Left), EVERY 5 MINUTES For 3 Doses
May use patients own supply
Pre-Op Day Of Procedure
tetracaine 0.5 % ophthalmic soln [42707] 1 drop, Eye (Left), ONCE For 1 Doses
To be given just before any other eye drops
Pre-Op Day Of Procedure
tropicamide (MYDRIACYL) 1 % ophthalmic soln [43208] 1 drop, Eye (Left), EVERY 5 MINUTES For 4 Doses, Pre-Op
Day Of Procedure
Medications - LEFT EYE - Non Formulary (Must Be Supplied By Patient) [135525]
bromfenac (XIBROM) 0.09 % ophthalmic soln NF
[107676]
Must use patient's own supply
Pre-Op Day Of Procedure
moxifloxacin (VIGAMOX) 0.5 % ophthalmic soln NF
[72666]
Must use patient's own supply
Pre-Op Day Of Procedure
nepafenac (NEVANAC) 0.1 % ophthalmic soln NF
[109336]
Must use patient's own supply
Pre-Op Day Of Procedure
Medications - LEFT EYE - Miscellaneous [135537]
phenylEPHRINE 10 % ophthalmic soln [41005] 1 drop, Eye (Left), ONCE PRN Starting today For 1 Doses,
Pupil does not dilate to 7-8mm after pre-op drops
If the patient's pupil does not dilate to 7-8 mm after pre-op
drops, give one drop in LEFT EYE.
Blood pressure must be less than or equal to 160/90.
Pre-Op Day Of Procedure
IntraOp
Medications - Non-Categorized [132969]
mitomycin (MUTAMYCIN) in water (sterile) 1 mL
ophthalmic injection [700539]
0.4 mg, Intraocular, ONCE For 1 Doses, IntraOp
Analgesia and Sedation [137850]
FENTanyl (SUBLIMAZE) injection RANGE [750047] 25-50 mcg, Intravenous, EVERY 1 HOUR PRN, pain, for 1
Minutes, IntraOp
midazolam (VERSED) injection RANGE [750056] 0.5-1 mg, Intravenous, PRN, Sedation
Give every 1-2 minutes as needed
If ordered IV: push rate 1 mg/minute.
IntraOp
Diagnosis
Diagnosis - Preoperative [2472]
Preoperative general physical examination [255757] Other specified pre-operative examination
Follow-Up
Follow-up [33406]
Follow-up Follow Up
Level of Service
Office Visit - Established Patient (Single Response) [573]
99211, Level 1 (5 min) LOS Code
99212, Level 2 (10 min) LOS Code
99213, Level 3 (15 min) LOS Code
99214, Level 4 (25 min) LOS Code
99215, Level 5 (40 min) LOS Code
Office Visit - Established Patient - Additional E & M (Single Response) [1104]
99211, Level 1, Modifier 25 (5 min) LOS Code
Page 3 of 5
Printed by GUETZLAFF, SCOTT F [SFG091] at 1/14/2016 2:10:35 PM

Copyright © 2015 University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:



















 
01/2016Lee Vermeulen, CCKM@uwhealth.org

99212, Level 2, Modifier 25 (10 min) LOS Code
99213, Level 3, Modifier 25 (15 min) LOS Code
99214, Level 4, Modifier 25 (25 min) LOS Code
99215, Level 5, Modifier 25 (40 min) LOS Code
Office Visit - Established Patient, Resident with Faculty (Single Response) [11788]
99211, Level 1 - Modifier GC (5 min) LOS Code
99212, Level 2 - Modifier GC (10 min) LOS Code
99213, Level 3 - Modifier GC (15 min) LOS Code
99214, Level 4 - Modifier GC (25 min) LOS Code
99215, Level 5 - Modifier GC (40 min) LOS Code
Office Visit - Established Patient - Additional E & M, Resident with Faculty (Single Response) [19509]
99211, Level 1, Modifiers 25 & GC (5 min) LOS Code
99212, Level 2, Modifiers 25 & GC (10 min) LOS Code
99213, Level 3, Modifiers 25 & GC (15 min) LOS Code
99214, Level 4, Modifiers 25 & GC (25 min) LOS Code
99215, Level 5, Modifiers 25 & GC (40 min) LOS Code
Office Visit - Established Patient, Resident Alone (Single Response) [11789]
99211, Level 1 - Modifier GE (5 min) LOS Code
99212, Level 2 - Modifier GE (10 min) LOS Code
99213, Level 3 - Modifier GE (15 min) LOS Code
Office Visit - Established Patient - Additional E & M, Resident Alone (Single Response) [19518]
99211, Level 1, Modifiers 25 & GE (5 min) LOS Code
99212, Level 2, Modifiers 25 & GE (10 min) LOS Code
99213, Level 3, Modifiers 25 & GE (15 min) LOS Code
Office Visit - New Patient (Single Response) [574]
99201, Level 1 (10 min) LOS Code
99202, Level 2 (20 min) LOS Code
99203, Level 3 (30 min) LOS Code
99204, Level 4 (45 min) LOS Code
99205, Level 5 (60 min) LOS Code
Office Visit - New Patient - Additional E & M (Single Response) [1105]
99201, Level 1, Modifier 25 (10 min) LOS Code
99202, Level 2, Modifier 25 (20 min) LOS Code
99203, Level 3, Modifier 25 (30 min) LOS Code
99204, Level 4, Modifier 25 (45 min) LOS Code
99205, Level 5, Modifier 25 (60 min) LOS Code
Office Visit - New Patient, Resident with Faculty (Single Response) [11791]
99201, Level 1 - Modifier GC (10 min) LOS Code
99202, Level 2 - Modifier GC (20 min) LOS Code
99203, Level 3 - Modifier GC (30 min) LOS Code
99204, Level 4 - Modifier GC (45 min) LOS Code
99205, Level 5 - Modifier GC (60 min) LOS Code
Office Visit - New Patient - Additional E & M, Resident with Faculty (Single Response) [19519]
99201, Level 1, Modifiers 25 & GC (10 min) LOS Code
99202, Level 2, Modifiers 25 & GC (20 min) LOS Code
99203, Level 3, Modifiers 25 & GC (30 min) LOS Code
99204, Level 4, Modifiers 25 & GC (45 min) LOS Code
99205, Level 5, Modifiers 25 & GC (60 min) LOS Code
Office Visit - New Patient, Resident Alone (Single Response) [11790]
99201, Level 1 - Modifier GE (10 min) LOS Code
99202, Level 2 - Modifier GE (20 min) LOS Code
99203, Level 3 - Modifier GE (30 min) LOS Code
Office Visit - New Patient - Additional E & M, Resident Alone (Single Response) [19520]
99201, Level 1, Modifiers 25 & GE (10 min) LOS Code
99202, Level 2, Modifiers 25 & GE (20 min) LOS Code
99203, Level 3, Modifiers 25 & GE (30 min) LOS Code
Office Consult (Single Response) [722]
Page 4 of 5
Printed by GUETZLAFF, SCOTT F [SFG091] at 1/14/2016 2:10:35 PM

Copyright © 2015 University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:



















 
01/2016Lee Vermeulen, CCKM@uwhealth.org

If Medicare patient, do not use Consult LOS. Choose an Established or New Patient LOS. Add the appropriate additional
E/M Code of 99354-99359 for prolonged office consultations in the LOS section of the Visit Navigator.
99241, Level 1 (15 min) LOS Code
99242, Level 2 (30 min) LOS Code
99243, Level 3 (40 min) LOS Code
99244, Level 4 (60 min) LOS Code
99245, Level 5 (80 min) LOS Code
Office Visit - Consult - Visit w/Procedure (Single Response) [103123]
If Medicare patient, do not use Consult LOS. Choose an Established or New Patient LOS. Add the appropriate additional
E/M Code of 99354-99359 for prolonged office consultations in the LOS section of the Visit Navigator.
99241, Level 1, Modifier 25 (15 min) LOS Code
99242, Level 2, Modifier 25 (30 min) LOS Code
99243, Level 3, Modifier 25 (40 min) LOS Code
99244, Level 4, Modifier 25 (60 min) LOS Code
99245, Level 5, Modifier 25 (80 min) LOS Code
Office Consult - Modifier 25 & GC (Single Response) [34450]
If Medicare patient, do not use Consult LOS. Choose an Established or New Patient LOS. Add the appropriate additional
E/M Code of 99354-99359 for prolonged office consultations in the LOS section of the Visit Navigator.
99241, Level 1, Modifier 25 & GC (15 min) LOS Code
99242, Level 2, Modifier 25 & GC (30 min) LOS Code
99243, Level 3, Modifier 25 & GC (40 min) LOS Code
99244, Level 4, Modifier 25 & GC (60 min) LOS Code
99245, Level 5, Modifier 25 & GC (80 min) LOS Code
No E&M with Procedure (Single Response) [721]
No Evaluation and Management Charge with Procedure
(Procedure Only)
LOS Code
Page 5 of 5
Printed by GUETZLAFF, SCOTT F [SFG091] at 1/14/2016 2:10:35 PM

Copyright © 2015 University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:



















 
01/2016Lee Vermeulen, CCKM@uwhealth.org