Wiki 1997 Guidelines for Specialty Eye Exam - Is dilation required?

[christi3_]

Hi There,

I'm trying to figure out whether dilation is required for a comprehensive eye examination to be coded. There is new technology out there that allows an optometrist to view the optic discs, retina, & vitreous bodies without having to use drops to dilate the pupil. However, according the 1997 guidelines, these areas of the eye must be "through dilated pupils (unless contraindicated)." This information can be found on the CMS website here:
https://www.cms.gov/Outreach-and-Ed...ork-MLN/MLNProducts/downloads/referenceii.pdf

I have been trying to see if these guidelines have been updated, without luck. There is an AAPC article that states the dilated exam is optional (https://www.aapc.com/blog/30462-split-decision-do-you-report-an-eye-exam-or-em/), but to me, you cannot get a comprehensive examination if it is not done (comprehensive is defined as "perform[ing] all elements identified by a bullet; document[ing] every element in each box with a shaded border and at least one element in each box with an unshaded border".

If anyone has additional information that could pass along, or if they have experience with the new technology that I described above & how to document it, I'd really appreciate any help I can get!

 

[JenniferB7]

Unfortunately, the guidelines have not been updated since 1997.

My understanding is that the dilation is required to bill an E/M service (99201-99215) to Medicare. It is not, however, required when billing 92002-92014 (see first link below from Railroad Medicare) as the 1995 & 1997 E&M Guidelines do not apply to General Ophthamological Service codes. This assumes the patient meets Medicare coverage criteria, which is very limited for vision exams.

I always find these articles helpful:
http://www.palmettogba.com/palmetto/providers.nsf/vMasterDID/8EELJL2417?open
http://www.optometricmanagement.com/issues/2004/december-2004/coding-eye-exams

Hope that helps!

 

[twdevore]

Dilation is or is not required?

Unfortunately, the guidelines have not been updated since 1997.

My understanding is that the dilation is required to bill an E/M service (99201-99215) to Medicare. It is not, however, required when billing 92002-92014 (see first link below from Railroad Medicare) as the 1995 & 1997 E&M Guidelines do not apply to General Ophthamological Service codes. This assumes the patient meets Medicare coverage criteria, which is very limited for vision exams.

I always find these articles helpful:
http://www.palmettogba.com/palmetto/providers.nsf/vMasterDID/8EELJL2417?open
http://www.optometricmanagement.com/issues/2004/december-2004/coding-eye-exams

Hope that helps!

Jennifer,
I'm not sure if you have a typo or not. I went to the links you posted and still am unsure if they answer the question as to whether dilation is required.

Do either of you have a definitive answer on this? Optometry is totally new to me.
Tim