I’m trying to figure out whether dilation is required for a comprehensive eye examination to be coded. There is new technology out there that allows an optometrist to view the optic discs, retina, & vitreous bodies without having to use drops to dilate the pupil. However, according the 1997 guidelines, these areas of the eye must be "through dilated pupils (unless contraindicated)." This information can be found on the CMS website here:
https://www.cms.gov/Outreach-and-Edu…eferenceii.pdf

I have been trying to see if these guidelines have been updated, without luck. There is an AAPC article that states the dilated exam is optional (https://www.aapc.com/blog/30462-spli…ye-exam-or-em/), but to me, you cannot get a comprehensive examination if it is not done (comprehensive is defined as "perform[ing] all elements identified by a bullet; document[ing] every element in each box with a shaded border and at least one element in each box with an unshaded border".

If anyone has additional information that could pass along, or if they have experience with the new technology that I described above & how to document it, I’d really appreciate any help I can get!