Ophthalmic Coding Specialist Practice Test

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What documentation is needed for tear gland deficiency before punctal plug insertion?

Patient's complete medical history
Schirmer tear test results
List of current medications
Previous eye treatments

The correct answer is: Schirmer tear test results

The requirement for documentation before inserting punctal plugs due to tear gland deficiency specifically focuses on the objective assessment of tear production. The Schirmer tear test is a standardized procedure that quantifies tear production, providing vital information about a patient’s tear gland functioning. A result from this test indicates whether the patient has adequate tear production or if they are experiencing dryness due to insufficient tears. While a complete medical history, a list of medications, and records of previous eye treatments can be helpful in understanding the patient's overall health and treatment context, they do not directly assess the specific condition related to tear production. The Schirmer tear test results provide definitive evidence of tear gland deficiency, making them essential documentation when considering treatment with punctal plugs. This objective data helps eye care professionals make informed decisions regarding the appropriate interventions for managing dry eye syndrome or other related conditions.