Wiki What constitutes dilation for 92004/92014?

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LauraNewYork

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I've been asked to audit (pre-billing) optometry claims. I don't have any experience in optometry. At my center, patients often refuse medication eye drop dilation, so the OD documents the refusal in the not and uses a darkened room. I've two questions:
  1. Is a darkened room considered sufficient for the fundus exam with dilation requirement to bill CPT 92004/92014?
  2. If darkened room is sufficient, does the documentation have to state that a darkened room is used, or is this assumed?
 
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Now that's an excellent question and you have really put some thought into it. Kudos for that!!
I don't know why folks object to the dilation: it can be uncomfortable and they may not have anyone who can drive them home so want to avoid that issue. A fundal exam could be done without dilation, but it will limit the visualization like trying to see inside a barrel through a nail hole. The fundus may or may not be totally visible and a darkened room is generally used for this procedure anyway.
Adding modifier 52 for reduced services doesn't seem right either as it might reduce payment for the service when the doctor had to work harder to visualize the whole retina. Can you check online ophthalmology resources for clarification since all I can give you is more stuff to think about. lol
 
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The short answer to your question is: NO, a darkened room is not dilation.

The standard of care for dilation is that one or more dilating medicated drops be instilled in the eyes to cause pharmacological dilation.

If the patient refuses dilation, the doctor needs to note that in the record. If they just refuse it for convenience sake, then the highest code you should bill, IMHO, would be either a 92002 or a 92012. If 99 codes are being used, then bill those at a level 3.

The only reason dilation may be skipped which would still allow you to bill the level 4 92 codes would be only if there is a valid medical reason, documented in the patient chart, for dilation not to be done.

Tom Cheezum, OD, CPC, COPC
 
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