MAY 19, 2016
Documenting Contraindication for Dilation
Question: During the Academy’s Codequest course this year, I was taught that when billing an Eye visit code without dilation, you will need to document why the patient wasn’t dilated. We were told auditors tend to look for dilation when you submit a comprehensive exam. My physician disagrees, however, and said he was taught not to document a negative. Can you give me more info on this topic?
Answer: If an exam element cannot be performed due to contraindication or because the patient cannot comply (e.g., infants, disabled persons), you may still count the element if you document the reason it’s not performed. This principle applies, whether billing E&M and or Eye visit codes. The CMS E&M chart audit guidelines (see page 23) include “Unless contraindicated” language.