Risk Management

Preoperative Medical Assessment

Many patients contemplating ophthalmic surgery have medical conditions that could increase the risk of the procedure and anesthesia/sedation. To prepare for and reduce the risks as much as possible, patients undergo a preoperative medical assessment that usually includes a history and physical examination (H&P). Such an assessment has been mandated by CMS (Centers for Medicare and Medicaid Services). Regulations passed in 2019, however, give surgery centers more flexibility in determining who needs a preoperative H&P and when it must be performed; these new regulations are discussed in Part 2. Ophthalmologists may play a role in these determinations. They may also be performing the H&P themselves. Preoperative medical assessment provides information to guide decision making about the preoperative medical assessment.