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New patient, Comprehensive or Intermediate exam

J

jessica907

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North Pole, AK
Hello - fairly new to Optometry/Ophthalmology coding... wanted to reach out for suggestion. Provider performed new, exam but didn't perform or document gross or confrontation visual field, nor vessels. Would this disqualify from a Comprehensive visit and down code to a Intermediate? I reached out to the provider and they mentioned as long as dilated exam was performed it's a Comprehensive exam. Patient is not a minor, in case that is factored.
 
Dilation is no longer required as part of a comprehensive exam. However, doing dilation DOES NOT make it a comprehensive exam. If the 99 E/M codes were billed, the code selection depends on MDM. For the 92 codes, they do have to do confrontation fields, adnexa exam and extra ocular muscle testing as part of the comprehensive exam.

Tom Cheezum, OD, CPC, COPC
 
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