January 01, 2009
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No special coding needed for ‘dilated eye exam’

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Charles B. Brownlow, OD, FAAO
Charles Brownlow

At least once a month I will receive an e-mail from a client wanting to be sure that he or she is billing properly for the dilated eye examination. Because this is one of my few true pet peeves with my colleagues, I am quick to respond and even quicker to remind myself to be polite and patient.

The idea that it is appropriate to bill more for a “dilated eye examination” than for an “undilated eye examination” is rooted in the history of optometry rather than medicine and, therefore, does not fit the nationally accepted rules for reporting or billing for medical services. Prior to the mid-1970s, doctors of optometry were not legally able to dilate pupils, so the eye exams provided by ODs were never done through dilated pupils. Hence, the some members of profession developed the collective notion of what was included in an “eye examination,” and prior to the mid 1970s that notion never included dilation.

Dilation considered routine part of eye exam

During the years prior to changes in practice laws to permit ODs to dilate pupils, ophthalmologists had already adopted dilation as a routine and expected part of their eye examinations. It was performed or not performed based on the doctor’s professional judgment, considering the needs of each patient. Whether it was done or not, it was not reported separately, but was, in either case, considered to be among the elements of the office visit.

As the coding for office visits matured, and the 90000 office visits gave way to the 99000 office visits in 1992, the definitions of the visits themselves became clearer. For example, the higher level 99000 office visits (99204, 99205 and 99215) include the requirement for a “comprehensive physical examination.”

Rules according to Documentation Guidelines

The 1997 Documentation Guidelines provide additional guidance for what qualifies as a “comprehensive physical examination, eyes.” The guidelines include 12 ophthalmic and two neurological/psychiatric elements, with examination of the discs and peripheral retina through dilated pupils as two of the 12 ophthalmic elements.

The Documentation Guidelines provide a means to measure the content of a medical record, while not requiring the completion of any specific tests during a patient visit. In other words, just as has always been the case, the doctor determines which tests to include in the examination (for example, to dilate or not). The doctor chooses the tests and then keeps a thorough record of all that is done. Then, when the visit is finished, the doctor chooses the correct code for the visit by comparing the content of the record to the national standards, that is, the definitions in Current Procedural Terminology from the American Medical Association and the Documentation Guidelines.

In the case of the 99000 office visit codes, the doctor will earn a higher level code if he or she completes a dilated evaluation of the discs and peripheral retina and a lower level if he or she decides dilation was not necessary during the visit. Either is correct, and the system permits the doctor to decide what services to provide, record and choose the code accordingly.

On the 92000 side, specifically the comprehensive ophthalmological service, 92004/92014, only the CPT definition needs to be considered, as no Documentation Guidelines exist for these codes. Again, the doctor’s professional judgment dictates which tests are performed during the visit, including whether the patient’s pupils are dilated. Then, the doctor and staff keep a thorough record of what is done and, finally, the code is chosen by comparing the content of that record to the requirements of the CPT definition as noted in the accompanying table.

Dilate when medically necessary

Elements of a comprehensive ophthalmological examAs you see from the definition, the authors of CPT expect the doctor to perform dilation when and if it is necessary, while permitting a visit to qualify as a comprehensive ophthalmological service, whether the patient is dilated or not.

Another way to look at it is that CPT clearly expects doctors to examine the internal structures of the eye by whatever means are appropriate, including dilation, if necessary, and does not intend the visit to be reported differently if dilation is used.

In short, I advise optometrists: Perform the tests you feel are necessary during every patient visit. If you feel ophthalmoscopy is necessary at a particular visit, dilate or do not dilate according to your professional judgment and the needs of the patient. If you do dilate, include the pharmaceutical you used, its concentration and the time of instillation in the patient record.

Choose the code for the visit, 99000 or 92000, based upon the CPT definitions for both series as well as the Documentation Guidelines for the 99000 series.

As you can see, there is no CPT code for a dilated eye examination. Dilation is not billed separately, but rather is included in the choice of codes, 99000 or 92000 visits.

Extended ophthalmoscopy billed differently

Continuing with the history lesson, when ODs began performing more dilated eye examinations, many felt the examination was different than they had previously done and should, therefore, be coded and reimbursed at a higher level. No other health care providers viewed it this way.

The only provision in CPT for ever billing any ophthalmoscopic examination separately or differently is found in the definition of a special ophthalmological service, “extended ophthalmoscopy.” Its CPT definition is “Ophthalmoscopy, extended, with retinal drawing (e.g., for retinal detachment, melanoma), with interpretation and report.” (Initial extended ophthalmoscopy is reported using 92225 and subsequent with 92226.)

The general statement that precedes this definition in CPT is “Routine ophthalmoscopy is part of general and special ophthalmological services whenever indicated. It is a non-itemized service and is not reported separately.”

Specific requirements

Most payers require a clear medical reason for billing 92225/92226, with an appropriate medical diagnosis and a reason for documenting a condition or departure from normal. Many payers require that the service includes two examination techniques, such as binocular indirect ophthalmoscopy and Volk (Mentor, Ohio) lenses at the slit lamp, for example, and scleral depression if the condition is peripheral.

Some payers require that the drawing be of a certain size (e.g., a minimum diameter of 4 inches), although national rules suggest only that the drawing must be large enough to permit following progress or changes in the condition from one visit to the next. Some payers require that the drawing be made with colored pencils, following the international standards for colored pencil retinal drawings.

Keep in mind that this service, as well as many other special ophthalmological services, always includes an interpretation and report, which should be clearly recorded on the patient’s record for the day, including the reason you did the test, the results you found during the test and your recommendations and decisions for continued care of the patient flowing from the test.

If you have a clear medical reason for performing extended ophthalmoscopy, I suggest that you code it using 92225/92226, making sure that the diagnosis supports the use of the code and that your medical record is complete enough to support challenges from the insurance carrier.

It is clear that the code is not to be used simply because you are dilating the patient, but rather to indicate that it was necessary for you to do something above and beyond the call of duty. In all other cases, consider the ophthalmoscopy, dilated or not, to be included as an element of the visit itself and, therefore, not reported or billed separately.

For more information:

  • Charles B. Brownlow, OD, FAAO, is a member of the Primary Care Optometry News Editorial Board, executive vice president of the Wisconsin Optometric Association and a health care consultant. He can be reached at PMI, LLC, 321 W. Fulton St., P.O. Box 608, Waupaca, WI 54981; (715) 942-0410; fax: (715) 942-0412; e-mail: Brownlowod@aol.com.