Increase your Coding Options for Patients Refusing Dilation

Published: 26th November 2010
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A patient shows up for an exam, however he won’t let the ophthalmologist dilate his pupils that day. Whatever the reason – time, the drive home, etc, you are stuck trying to find the best way to report a dilation at a separate visit.

Most Medicare carriers assume that a dilated fundus exam will be part of any comprehensive eye exam you carry out and bill with 92004 or 92014.

Without dilation, you cannot carry out the fundus exam and without the fundus exam, you don’t have a comprehensive service.

Count two visits as one service

According to CPT, a comprehensive ophthalmological service "often includes" examination with dilation, therefore dilation is not necessarily required to bill 92004 or 92014. But some payers and state specific guidelines may have their own dilation requirements. For instance, according to Trailblazer, the 92004/92014 exams should be done under dilation unless "medically contraindicated. Check with your carrier if you get a denial you think is unfounded.

Do not submit bill until second appointment

The real challenge comes into play when you are expecting the patient to come back for the dilated exam and he never shows up. This’s a difficult situation as you do not want to bill for services not rendered, nor do you want to undercode a visit.

If you bill the insurance company for the initial visit before the time of the second visit, and the patient does not show up, document carefully that the patient refused dilation on the first visit, scheduled a return visit and then refused to keep the appointment. But then it is not recommended to bill for services that have not been rendered or refused by patients under any circumstances.

Better idea: Do not file the claim until the second appointment. You could downcode to a 92002/92012 (intermediate service) if the patient failed to show up and you wouldn’t have to pursue the patient to return. You couldn’t bill the comprehensive codes in this case as the first visit didn’t include a dilated fundus examination.

For more on this and other CPT coding updates, sign up for a medical coding guide like Supercoder!

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