How To Use CPT Code 2023F

CPT 2023F describes the performance of a dilated retinal eye exam by an ophthalmologist or optometrist for a diabetic patient without evidence of retinopathy. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, and examples.

1. What is CPT Code 2023F?

CPT 2023F can be used to describe the performance of a dilated retinal eye exam by an ophthalmologist or optometrist for a diabetic patient without evidence of retinopathy. This code is used when the provider instills dilating drops into the patient’s eye to widen the pupil and examines the back of the eye, focusing on the retina and optic nerve, for signs of damage or disease.

2. Official Description

The official description of CPT code 2023F is: ‘Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed; without evidence of retinopathy (DM).’

3. Procedure

1. The ophthalmologist or optometrist instills dilating drops into the patient’s eye to dilate the pupil.
2. Using a bright light and an ophthalmoscope, the provider examines the back of the eye, focusing on the retina and optic nerve.
3. The provider looks for signs of damage or disease, specifically checking for evidence of retinopathy.
4. The findings of the exam are interpreted and documented by the provider.
5. The documented findings are reviewed by the provider to ensure accuracy and completeness.

4. Qualifying circumstances

CPT 2023F is applicable to diabetic patients without evidence of retinopathy who require a dilated retinal eye exam. Diabetes mellitus (DM) is a disease in which the body’s production or utilization of insulin is insufficient, leading to high levels of blood glucose and subsequent complications. The provider performing the exam must be an ophthalmologist or optometrist, and the exam must show no evidence of retinopathy, which is damage to the blood vessels feeding the retina.

5. When to use CPT code 2023F

CPT code 2023F should be used when an ophthalmologist or optometrist performs a dilated retinal eye exam for a diabetic patient without evidence of retinopathy. It is important to note that this code should not be used for patients with evidence of retinopathy, as a different code (such as CPT 2022F) would be appropriate in those cases.

6. Documentation requirements

To support a claim for CPT code 2023F, the provider must document the following information:

• Diagnosis of diabetes mellitus and absence of retinopathy
• Performance of a dilated retinal eye exam
• Interpretation of the findings
• Review of the documented findings

7. Billing guidelines

When billing for CPT code 2023F, ensure that the provider performing the exam is an ophthalmologist or optometrist. This code should only be reported for diabetic patients without evidence of retinopathy. It is important to note that CPT code 2023F should not be reported with other codes such as CPT codes 2020F-2022F, which are used for dilated retinal eye exams in patients with evidence of retinopathy.

8. Historical information

CPT code 2023F was added to the Current Procedural Terminology system on October 1, 2019. There have been no updates to the code since its addition.

9. Examples

1. An ophthalmologist performing a dilated retinal eye exam for a diabetic patient without evidence of retinopathy.
2. An optometrist examining the back of the eye, focusing on the retina and optic nerve, for signs of damage or disease in a diabetic patient without evidence of retinopathy.
3. A provider instilling dilating drops into the patient’s eye to widen the pupil and performing a thorough examination of the retina and optic nerve in a diabetic patient without evidence of retinopathy.
4. An ophthalmologist interpreting the findings of a dilated retinal eye exam and documenting them in the patient’s chart for a diabetic patient without evidence of retinopathy.
5. An optometrist reviewing the documented findings of a dilated retinal eye exam to ensure accuracy and completeness in a diabetic patient without evidence of retinopathy.
6. A provider performing a comprehensive dilated retinal eye exam, specifically checking for evidence of retinopathy, and documenting the findings for a diabetic patient without retinopathy.
7. An ophthalmologist or optometrist conducting a dilated retinal eye exam and interpreting the results for a diabetic patient without evidence of retinopathy.
8. A provider performing a thorough examination of the back of the eye, focusing on the retina and optic nerve, and documenting the findings in a diabetic patient without evidence of retinopathy.
9. An optometrist instilling dilating drops into the patient’s eye, dilating the pupil, and conducting a dilated retinal eye exam for a diabetic patient without evidence of retinopathy.
10. An ophthalmologist reviewing the documented findings of a dilated retinal eye exam for a diabetic patient without evidence of retinopathy to ensure accuracy and completeness.