Question: Our billing department has stated dilation is only necessary for Eye visit codes, but not E/M codes. Is our pediatric ophthalmologist not required to dilate when billing 99214?

Answer: Prior to Jan 2021, dilation was required for E/M CPT codes 99204, 99205 and 99215 unless contraindicated. Most auditors know where to look for dilation, so best even when billing the Eye visit codes, to indicate the contraindication/poor cooperation from child if unable to dilate.

Prior to Jan 2021, when using the audit tool for E/M, a detailed exam was nine to 12 exam elements. Therefore, some exam elements may not be performed. A detailed history and moderate decision making are appropriate for 99214. The physician should perform the exam elements based on medical necessity; often this includes dilation.

After Jan 2021, dilation is not required on any level of E/M. It is the physician’s decision to dilate or not.