Considering several of this issue’s features focus on examination of the posterior pole, an update on the compliance issues we have to follow would be useful. Let’s start with some foundational concepts:

  1. Dilation of the eye for examination of the posterior pole is part of an examination technique and not a distinct and separate procedure. There is no CPT code for dilating an eye. It is typically interpreted by the courts and insurance carriers as using a pharmaceutical agent to affect pupillary function.
  2. According to the CPT, dilation is not mandatory when performing any 920XX code, but is designated “as indicated.”1 Additionally, dilation is part of the definition of all 920XX codes, should it be performed, and is not a separate billable event.
  3. When the retinal components (optic discs, including size, cup-to-disc ratio, appearance and nerve fiber layer, as well as posterior segments such as the retina and vessels) of a single-system eye examination are performed using a 992XX evaluation and management code, it must be done through a dilated pupil, unless contraindicated because of age or medical reasons.2
  4. For any special ophthalmic procedure, whether on the date of service or after, you must provide a statement of medical necessity for the specific tests in your assessment and plan for the office visit.
  5. A special ophthalmic test—by virtue of having its own CPT code and having its own specific definition—is not part of any office visit, be it an ophthalmic (920XX), or evaluation and management (992XX) code.
  6. All special ophthalmic tests require an interpretation and report distinct and separate from any notes contained in the medical record for the office visit itself. A typical interpretation and report should contain:
  • Clinical findings: pertinent findings regarding the test results
  • Comparative data: comparison to previous test results (if applicable)
  • Clinical management: how the results will affect management of the condition
    • Change, increase or stop medication
    • Recommendation for surgery
    • Recommendation for further diagnostic testing
    • Referral to a specialist or subspecialist for additional treatment

Also, remember that no special ophthalmic test is deemed complete and billable until the interpretation and report is completed.

So, Better or Just Easier?

Now that we have gotten some foundational elements established, let’s discuss a common coding and compliance issue for a practice: replacing dilation with fundus imaging. Some clinicians inappropriately use a screening image of the retina as a substitute for dilating the patient. While proponents of retinal imaging will argue that it is much more convenient, the patient prefers it, or it’s just plain easier to communicate to the patient, there is not a circumstance that I am aware of for which a routine retinal screening image is either a legal or clinical substitute for dilating the patient.

If you are performing a screening test, the appropriate code to use is S9986—not medically necessary service. Be sure the patient understands it is not medically necessary, they are financially responsible for the test and that it is performed before they see the clinician. Taking a retinal image does not meet the 992XX component requirements for physically examining the retina.

Although the developmental pace of technology for better patient care is phenomenal, the rules have not yet incorporated these advances to a point where we can take advantage of the additional convenience. So, until the rules change, love and embrace your technology, but make sure you don’t substitute your clinical examination skills with it; rather, complement your own physical examination.

Send questions and comments to

1. American Medical Association. 2017 CPT Professional Edition. 2016:598.
2. Centers for Medicare and Medicaid Services. Evaluation & Management Guidelines. 1997:27.