# 2021F Dilated Macular or Fundus Exam Performed, Including Documentation or G8397?



## Walpitgood (Jan 26, 2018)

Greetings. Large Ophthalmology Group. Patient was seen a week before for New Patient Routine eye exam without dilation (cpt code 92002)- Patient is on High-Risk medication for HTN, Thyroid dysfunction, and is BORDERLINE diabetic. Patient seen again yesterday for *JUST* the Dilated macular or fundus exam performed, with all documentation salient to fundus findings. I see that the provider reported 2021F. Wouldn't the better option have been to either 1) Bill G8397 or 2) Inform the patient that they ".. have medical conditions that warranted further evaluation with a Dilated Medical Exam, so we will just skipt the DFE Screening (that is already included in the patient's insurance) and instead do the more thorough retinal Medical exam that is billed through your Medical Insurance." ? This could have then been billed with a CPT Code of 992**.  Your input is strongly encouraged. I look forward to your replies.


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