Coding Strategy

Routine Dilation?

It’s your call. Here’s why.

DOUGLAS K. DEVRIES, O.D.

The answer to the question, “should I routinely dilate when performing a comprehensive examination?” is as unclear as the eyesight of a patient who requires a −35.00D prescription. Therefore, the choice is literally and figuratively in your hands.

Here are three issues to consider before making this decision:

1. Health insurance company policy

Many insurers, in defining the need to look through a dilated pupil, use the words “should,” “often” or “usually.” As a result, several practitioners feel it is arguable that the dilation can be substituted with imaging technology or photography. But, since these are substitutions, the question of charging the patient by utilizing an advanced beneficiary notice for a non-covered service is a gray area. Another area of caution: billing for a comprehensive exam, calling it a comprehensive exam and then charging the patient an additional fee for performing a dilated exam. Unless you have performed an extended ophthalmoscopy, accompanied by a retinal drawing, you shouldn’t bill separately for the dilation.

The bottom line is that if an insurer’s position on dilation is not 100% clear, you should contact the insurer directly, and request their position in writing. This way, you can protect yourself and your practice from future audits and possible malpractice lawsuits.

The choice to dilate is yours.

2. Immediate referral

Dilating the patient should not be a choice unless your exam is followed by an immediate referral for further evaluation.

Keep in mind that dilating to perform a fundus exam at every comprehensive exam (92004 or 92014) ensures your level of care from a medicolegal standpoint is unquestioned. In addition, you know you are within the guidelines for every insurer (as described above).

3. Imaging

Imaging is not considered a substitute for performing a dilated examination until proven in a court of law, according to current standard of care. So, imaging is not regarded legally as the standard of care.

Making the choice

Based on the issues presented above, unless you are contractually obligated via provider agreement to dilate to perform a fundus exam, the choice is yours and yours alone. OM

DR. DEVRIES HAS A DEGREE IN FINANCIAL MANAGEMENT FROM THE UNIVERSITY OF NEVADA SCHOOL OF BUSINESS AND IS CO-FOUNDER OF EYE CARE ASSOCIATES OF NEVADA, A MEDICAL/SURGICAL CO-MANAGEMENT REFERRAL PRACTICE. E-MAIL HIM AT DRDEVRIES@NVELASER.COM, OR SEND COMMENTS TO OPTOMETRICMANAGEMENT@GMAIL. COM.