Some patients come to your office for an eye exam and refuse to be dilated. Dilation is almost always harmless in the long term, but it does come with short-term side effects, including light sensitivity, blurry vision, difficulty driving immediately after dilation, trouble focusing on close objects and stinging when the drops are instilled. So, it is reasonable to ask if you should insist on a dilated fundus exam (DFE) as part of a comprehensive eye exam. Here’s what you need to consider.

Q. Why would you not dilate?

A. Besides patient inconvenience, there are other more serious reasons not to dilate the patient (Table). Consequently, a comprehensive eye exam, reported with either an evaluation and management (E/M) code (992xx) or an eye code (920xx), does not mandate a DFE.¹ The changes to the E/M coding system, effective Jan. 1, 2021, further emphasize this point because physicians need only perform and document “… a medically appropriate examination and/or evaluation.”²

That is very different from the 1997 E/M guidelines for single organ specialties that stipulated “ophthalmoscopic examination through dilated pupils unless contraindicated.”³ Importantly, “not mandatory” does not mean unnecessary or not recommended. Instead, dilation is at the physician’s discretion and guided by training, experience and evidence-based clinical practice guidelines.

Q. What are the arguments in favor of dilation?

A. In most cases, it is considered the standard of care. The AAO Preferred Practice Pattern (PPP), Comprehensive Adult Medical Eye Evaluation (2020) states, “The comprehensive eye examination ... usually includes ... evaluation of structures situated posterior to the iris is best performed through a dilated pupil.” When patients present for an eye exam with comorbid systemic disease that might affect the eyes, such as diabetes mellitus, the argument for a DFE is more urgent and persuasive. Likewise, known or suspected ophthalmic disease typically found in the posterior segment argues for a DFE.

Insistence on a DFE may also be motivated by potential malpractice litigation against ophthalmologists that is frequently based on missed retinal pathologies due to failure to dilate. The medico-legal issue may outweigh any other consideration. Picture yourself in a courtroom trying to complete this sentence if you missed something that could have been picked up on a DFE: “Your Honor, the reason I chose not to dilate was _______.” Anything you would put in the blank pales beside what the patient might lose.

In a study that compared exams through a dilated and a natural pupil, the authors found a significant number of retinal anomalies were missed, some very serious, and concluded that “... dilation should be strongly considered for all patients so as to optimize the probability of detecting fundus anomalies.”⁴

Q. What about imaging as an alternative to dilation?

A. In our experience with clients, a few offer ultra-widefield imaging (UWFI) as a screening service prior to an eye exam and make an additional charge to the patient for a non-covered service. No doubt, some patients believe (erroneously) that UWFI is a substitute for a DFE. While UWFI can show most of the retina, it will not reveal lesions anterior to the equator.

Binocular indirect ophthalmoscopy⁵ (BIO) remains the gold standard. Some have observed that BIO, particularly on an uncooperative patient, may be poorly performed and miss abnormalities or disease, and that UWFI can help point the ophthalmologist or optometrist in the right direction where it identifies something suspicious. One study showed a 30% increase in retinal lesion discovery compared with traditional DFE alone.⁶

In the AAO’s PPP for Posterior Vitreous Detachment, Retinal Breaks and Lattice Degeneration, it states, “Wide-field color photography can detect some peripheral retinal breaks but does not replace careful ophthalmoscopy and may be useful in patients not able to tolerate the exam.”⁷

A representative LCD on fundus photography by National Governmental Services, LLC (L33567) states, “Fundus photography is not a substitute for an annual dilated examination by a qualified professional.”

Significantly, the definition of an eye exam does not, in any instance, include fundus photography; rather, it mentions ophthalmoscopy — which is dynamic and personally performed by the physician. Going further, extended ophthalmoscopy (92201, 92202) is not imaging.⁸ We conclude that UWFI should not be offered solely as a substitute for dilation. OM

REFERENCES

1. 2021 CPT Professional Edition
2. CPT Evaluation and Management (E/M) Office or Other Outpatient (99202-99215) and Prolonged Services (99354, 99355, 99356, 99XXX) Code and Guideline Changes. American Medial Association. June 2019. https://tinyurl.com/8a2d9hb7 . Accessed March 23, 2021.
3. 1997 Documentation Guidelines for Evaluation and Management Services. Centers for Medicare and Medicaid Services. https://tinyurl.com/5fkp88sa . Accessed March 23, 2021.
4. Siegel BS, Thompson AK, Yolton DP, et al. A comparison of diagnostic outcomes with and without pupillary dilation. J Am Optom Assoc. 1990; 61:25-34.
5. Binocular Indirect Ophthalmoscopy. America Academy of Ophthalmology Eyewiki. https://eyewiki.aao.org/Binocular_Indirect_Ophthalmoscopy . Accessed March 23, 2021.
6. Brown K, Sewell JM, Trempe C, et al. Comparison of image-assisted versus traditional fundus examination. Eye Brain. 2013;5:1-8.
7. Posterior Vitreous Detachment, Retinal Breaks, and Lattice Degeneration PPP 2019. American Academy of Ophthalmology. https://www.aao.org/preferred-practice-pattern/posterior-vitreous-detachment-retinal-breaks-latti . Accessed March 23, 2021.
8. Local Coverage Determination: Ophthalmology: Posterior Segment Imaging (Extended Ophthalmoscopy and Fundus Photography) (L33567). Centers for Medicare and Medicaid Services. https://tinyurl.com/37xnms6p . Accessed March 23, 2021.

Suzanne L. Corcoran is vice president of Corcoran Consulting Group. She can be reached at (800) 399-6565 or www.corcoranccg.com .