OCT 13, 2023
Declined IOP Check
We encountered a situation where a patient does not like having their pressure checked and declined intraocular pressure (IOP) measurements during the exam. Does this refusal mean that the exam should be classified as intermediate since we couldn't complete all 12 elements, or can we still bill it as a comprehensive exam because the measurement was offered and declined?
Answer:
If you are unable to perform elements due to medical contraindication, you may document the reason. A patient requesting not to have IOP measured due to discomfort does not qualify as medically contraindicated.
Depending on the payer and their coding guidance you may be able to consider an applicable E/M code. Visit aao.org/em for E/M coding resources.