Ophthalmology and Optometry Coding Alert
Code an Incomplete Exam After Completion
Test your coding knowledge. Determine how you would code this situation before looking at the box below for the answer. Question: We have had a lot of patients come in for regular eye exams, but when it is time for them to have their eyes dilated for the glaucoma check, they insist on returning at a more convenient time. How should I handle billing and submitting claims for the initial visit and the follow-up visit? Are they considered separate visits? Maryland Subscriber
Answer: It is not uncommon for patients undergoing a routine eye exam to request postponing the dilation portion of the exam until a later date. This is typically reflected in the medical record as "return for dilated follow-up" or "DFE" (dilated fundus examination). As for the selection of codes, you will most likely end up with two intermediate or expanded problem-focused visits instead of one comprehensive service.
You should bill for the office visits rendered on both days. Each visit will contain the chief complaint or reason the patient is being seen, an initial or interval history, examination of findings, and an impression and plan all of which, in addition to the scheduling of the patient, incur costs to your practice, so you should be reimbursed for your services.
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