Wiki dilated fundus exams

[PattyGreen]

What in the note indicates a dilated fundus exam if the physician does not use the word "dilated"? Can you bill a comprehensive eye code if the word "dilated" is not used? I am looking for a resource that I can reference the rules of documentation for Ophthalmology. Thanks!

 

[fishbite2]

Look for a notation about mydriatic drops. Most ophthalmologists will write what % drop was used and what time.