Written by the AOA’s Coding & Reimbursem*nt 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.
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The provided article, sourced from the January/February 2023 edition of AOA Focus and authored by the AOA’s Coding & Reimbursem*nt Committee, delves into crucial aspects of optometric practice related to eye examinations, particularly addressing the misconceptions surrounding dilation requirements and coding implications. Let's break down the concepts covered:
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Comprehensive Eye Exams vs. Intermediate Exams: The article highlights that dilation is not mandatory for coding comprehensive eye exams (CPT codes 92004 and 92014) or intermediate exams (CPT code 92012). The key lies in correctly documenting components such as history, observation, external and ophthalmoscopic examinations, gross visual fields, and sensorimotor assessments, as per CPT definitions.
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CPT Definitions and Guidelines: The article emphasizes that while comprehensive exams encompass various evaluations of the visual system, including dilation when indicated, the decision to dilate a patient is within the optometrist's professional judgment. However, thorough documentation, especially concerning an ophthalmoscopic examination, is pivotal.
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Importance of Dilation in Clinical Practice: Despite not being a strict requirement for coding, dilation is strongly recommended unless medically contraindicated. The article underscores the significance of dilation as a standard of care to prevent missed diagnoses, which can lead to malpractice suits. It advocates for meticulous documentation if a patient refuses dilation.
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E&M Coding Changes: The article also touches upon the changes in Evaluation and Management (E&M) codes by CMS and AMA, which now emphasize the need for "a medically necessary" examination rather than specific components. This shift impacts the way eye examinations are billed.
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Payer Contractual Obligations: Payer contracts might stipulate specific requirements for comprehensive eye exams, potentially mandating dilation for certain conditions like diabetes. Failure to adhere to these contractual obligations could result in violations and pose legal ramifications.
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Summation and Recommendations: The article concludes by reiterating that while dilation isn't obligatory for coding, it aligns with the highest standards of care. Optometrists are advised to document refusal of dilation, offer subsequent visits for dilation, and review payer-specific requirements for comprehensive exams.
The article underscores the delicate balance between coding guidelines, clinical standards, and contractual obligations that optometrists must navigate when conducting eye examinations, providing a comprehensive overview for practitioners aiming to optimize their coding practices while maintaining patient care standards.
