Wiki split?

[lfoote_25]

I have a pt who had a comprehensive exam but didnt do dilation at that visit.
patient came back a month later to have that portion done. provider understood this but still did and intermediate exam and at that time dilation.
is this billable as a second exam?

 

[mzkandyd]

You don't necessarily have to downcode to intermediate because the dilation wasn't performed. If you are using the 92xxx codes, the determining factor is the IOP AND Slit Lamp/Biomiscroscopy exam, if those are missing then you downcode. Now, depending on what was performed during the 2nd visit will ....we know it wasnt just the dilation because the provider has to look at the patients eyes using the slit lamp after dilation, I would hope that IOPs were obtained prior to the dilation drops...if so, then proceed with either intermediate or comp exam. If the patient had just dilation and exam...and has medical dx such as 250.xx I would code with regular E&M codes, if they still have refractive dx, then code 92012.

I have a pt who had a comprehensive exam but didnt do dilation at that visit.
patient came back a month later to have that portion done. provider understood this but still did and intermediate exam and at that time dilation.
is this billable as a second exam?

 

[lfoote_25]

thanks for the help greatly appreciated.