Optometry Coding & Billing Alert

Question: Can we bill for a comprehensive eye exam with 92004/92014 if the optometrist did not dilate the patient and examine the eyes through dilated pupils?

Massachusetts Subscriber

Answer: There are some instances when the optometrist may not think that dilation is needed for a thorough exam. A patient may have large pupils that the optometrist doesn't need to dilate to get a good view. Or, the optometrist may think that a patient with certain conditions shouldn't risk dilation. Such cases are the exception to the rule, but they shouldn't prevent you from billing for comprehensive services.

CPT states that a comprehensive ophthalmological service "often includes" examination with dilation, therefore dilation is not necessarily required to bill 92004 (Ophthalmological services ...; comprehensive, new patient) or 92014 (Ophthalmological services ...; comprehensive, established patient). However, some payers may have their own dilation requirements. For example, Trailblazer says the 920x4 exams should be done under dilation "unless medically contraindicated." Check with your carrier if you receive a denial you think is unfounded.