Several issues are surfacing in vision care regarding "pupil dilation" (the 
actual process of inducing mydriasis with various drugs) and "dilated 
examination" of certain parts of the eye (retina, vitreous, lens, 
etc.).  Pupil Dilation procedure (decide which drop, put it in, wait 30-40 
minutes) is used to give the doctor a better view of certain eye 
structures, but it has never had its own procedure code and doctors rarely 
charge specifically for the service of inducing dilation.  A few vision 
plans, however, do pay separately for the dilation service and presently 
have no way to code it.

CPT has wrestled with the issue for years and the current CPT definitions 
of most ophthalmological services leave the dilation optional.  A "92004" 
comprehensive eye examination, for example, must include a look at the 
retina, but the doctor can dilate or not dilate without affecting the 
validity of the 92004 code.

My main question has to do with local medical quality guidelines developed 
unilaterally by some payors that have the effect of expanding the CPT-4's 
definition of a coded service.  For example, can a local Medicare carrier 
state that all 92004 and 92002 procedures "must be done with dilated 
pupils", if the CPT code definition is silent on "dilation" or leaves it 
optional?

It is beginning to look like we should request a CPT code for the dilation 
procedure, but my present question is only regarding the legality of  local 
medical review policies essentially expanding a code's definition.

Thanks,
-Chris

Christopher J. Feahr, OD
http://visiondatastandard.org
[EMAIL PROTECTED]
Cell/Pager: 707-529-2268        


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