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.

Q. Why would you not dilate?

A. Besides patient inconvenience, there are other, more serious, reasons not to dilate the patient (sidebar). 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 January 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’s Preferred Practice Pattern (PPP) for comprehensive adult medical eye evaluation from 2020 states that “... evaluation of structures situated posterior to the iris is best performed through a dilated pupil.”⁴ 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 medicolegal issue may outweigh any other consideration. Anything you would tell a judge about the reason you chose DFE pales beside what the patient might lose.

In a study that compared exams through a dilated and 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.”⁵

Q. What about imaging as an alternative to dilation?

A. In our experience with clients, a few offer ultrawidefield (UWF) imaging as a screening service prior to an eye exam and make an additional charge to the patient for a noncovered service. Some patients might believe that UWF imaging is a substitute for a DFE, but this is not the case. While UWF imaging can show most of the retina, it will not reveal lesions anterior to the equator.

Binocular indirect ophthalmoscopy (BIO) remains the gold standard.⁶ Therefore, we conclude that UWF imaging should be used only as an adjunct to a DFE that includes careful peripheral retinal examination.

Some have observed that BIO, particularly on an uncooperative patient, may be poorly performed and miss abnormalities or disease, and that UWF imaging can help point the ophthalmologist in the right direction where it identifies something suspicious. One study showed a 30% increase in retinal lesion discovery compared with traditional DFE alone.⁷ The AAO’s PPP for posterior vitreous detachment, retinal breaks, and lattice degeneration 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.”⁸

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.⁹ We conclude therefore that UWF imaging should not be offered solely as a substitute for dilation. RP

REFERENCES

1. 2022 CPT Professional Edition.
2. American Medical Association. CPT evaluation and management (e/m) office or other outpatient (99202-99215) and prolonged services (99354, 99355, 99356, 99xxx) code and guideline changes. June 2019. Accessed August 10, 2022. https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf
3. Health Care Financing Administration. 1997 documentation guidelines for evaluation and management services. Accessed August 3, 2022. https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnedwebguide/downloads/97docguidelines.pdf
4. AAO Preferred Practice Pattern Guidelines. Comprehensive adult medical eye examination. American Academy of Ophthalmology; 2020. Accessed August 12, 2022. https://www.aao.org/preferred-practice-pattern/comprehensive-adult-medical-eye-evaluation-ppp
5. Siegel BS, Thompson AK, Yolton DP, Reinke AR, Yolton RL. A comparison of diagnostic outcomes with and without pupillary dilatation. J Am Optom Assoc. 1990;61(1):25-34.
6. America Academy of Ophthalmology. Binocular indirect ophthalmoscopy. Accessed August 10, 2022. https://eyewiki.aao.org/Binocular_Indirect_Ophthalmoscopy
7. Brown K, Sewell JM, Trempe C, et al. Comparison of image-assisted versus traditional fundus examination. Eye Brain. 2013;5:1-8. https://pubmed.ncbi.nlm.nih.gov/28539783/
8. AAO Preferred Practice Pattern Guidelines. Posterior vitreous detachment, retinal breaks, and lattice degeneration. American Academy of Ophthalmology; 2019. Accessed August 10, 2022. https://www.aao.org/preferred-practice-pattern/posterior-vitreous-detachment-retinal-breaks-latti
9. National Governmental Services. LCD L33567. Posterior segment imaging (extended ophthalmoscopy and fundus photography). Accessed August 10, 2022. https://tinyurl.com/4b5asc3a