Most asked coding questions: dilation

Excerpted from the January/February 2023 edition of AOA Focus.

The AOA’s coding experts offer guidance to support doctors and staff in providing the best possible patient care while ensuring accurate reimbursements are received.

Here are some recent questions posed to the experts and their answers.

Are doctors of optometry required to perform a dilation to code for either a comprehensive eye exam or an intermediate exam (92004 or 92014)?

No. However, some payers and state-specific guidelines may have their own dilation requirements. Doctors of optometry should still consider dilation essential unless medically contraindicated. 

Do current clinical practice guidelines recommend dilation as the standard of care?

Yes. 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. 

Does dilation have to be performed on the same day as the rest of the exam?

If the patient comes back to complete the exam another day, doctors of optometry can report 92004 or 92014 once, with either date as the date of service.

What should doctors of optometry do if a patient refuses dilation?

Clearly and thoroughly document in the patient’s medical record their reasoning for their refusal. While malpractice suits against doctors of optometry are rare, 45% result from missed diagnoses. And the mistake that most often leads to a missed diagnosis is not dilating the patient.