2 points to keep in mind when patients decline dilation

Written by the AOA’s Coding & Reimbursement Committee. Excerpted from page 44 of the January/February 2023 edition of AOA Focus.

Many doctors of optometry have encountered something similar to the following scenario: A patient arrives in the afternoon for a comprehensive eye exam and informs the optometrist that they will be driving due west for several hours immediately after the appointment, and thus requests not to be dilated. The patient includes the caveat that they are going on vacation and will not be able to return in subsequent days for dilation. Therefore, the optometrist decides to move forward with the comprehensive eye exam but code for an intermediate exam (CPT code 92012), believing that they will not be able to code for a comprehensive exam without dilating the patient. This raises two key points that all doctors of optometry must keep in mind when examining patients who decline dilation.

First, dilation is not required for the doctor of optometry to code for either a comprehensive eye exam or an intermediate exam. In the Introduction to Ophthalmology section of the CPT, the definition for a comprehensive ophthalmologic service (CPT codes 92004 and 92014) is the following:

Comprehensive ophthalmological services describe a general evaluation of the complete visual system. The comprehensive services constitute a single service entity but need not be performed at one session. In other words, the patient can return for dilation in a subsequent visit. The service includes history, general medical observation, external and ophthalmoscopic examinations, gross visual fields and basic sensorimotor examination. It often includes, as indicated: biomicroscopy, examination with cycloplegia or mydriasis, and tonometry. It always includes initiation of diagnostic and treatment programs.

The words “often includes” mean may or may not include. According to the definition, the doctor must document an ophthalmoscopic examination. However, unless it is specifically required by a payer, including a vision plan, dilation is up to the professional judgment of the doctor of optometry.

Second, even though coding 92004 and 92014 does not require dilation, doctors of optometry should still consider dilation essential unless medically contraindicated. Current clinical practice guidelines recommend dilation as a standard of care. While malpractice suits against doctors of optometry are rare, 45% result from missed diagnoses, according to the National Practitioner Data Bank. And the mistake that most often leads to a missed diagnosis is not dilating the patient. Thus, while dilation is optional when coding for a comprehensive eye exam, it should still be performed out of adherence to the highest standard of care. If the patient refuses dilation, the doctor of optometry should first clearly and thoroughly document in the patient’s medical record their reasoning for their refusal. Secondly, because a comprehensive eye exam can be performed over the course of multiple visits, the doctor of optometry should offer the patient a subsequent visit, during which the dilation can be performed.

In 2021, the Centers for Medicare & Medicaid Services and the American Medical Association released new definitions and guidelines for billing Evaluation and Management codes (E&M codes). These E&M codes no longer define what the components are in an eye examination, but rather require the provider to perform “a medically necessary” examination.

Additional consideration to this issue is payer contracts. There are some plans that require dilation as part of their comprehensive eye examination, particularly for diabetic patients. If a health or vision plan requires dilation for a comprehensive service and it is not performed, then the doctor of optometry might be in violation of the contract. Doctors of optometry should carefully review the requirements for a comprehensive eye exam established by each payer with whom they have a contract, as well as the requirements for the clinical quality measures they choose to use.

In summation, dilation is not required when coding for a comprehensive eye exam following CPT guidance. However, it is the standard of care and should be performed unless the patient explicitly refuses it, and that reason should be documented in the chart.