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 By Neil B. Gailmard, OD, MBA, FAAO, Editor August 26, 2009 - Tip #394 
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Should you charge for dilation?


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Additional Information

I think the practice of charging an additional fee for pupil dilation is on the decline, but I still see it in a surprising number of practices. I don't care for the idea. I think it's best to set the exam fee high enough that dilation can just be included when indicated. Here's why:

  • It's old school. Dilation is such a common, frequent and routine part of clinical care today that the best practices don't charge extra for it. I think doing so makes the practice look out of date.
  • It's bad policy. Charging an extra fee for dilation is an incentive for the patient to refuse the procedure and, in the interest of good eye care and ocular health, our office policies shouldn't foster that. Additionally, if you recommend dilation and then generate an additional fee for it, some patients could misconstrue that you recommended the procedure just for the increased revenue.
  • It's inefficient. If you charge an additional fee for a service, you owe it to the consumer to explain that in advance. Sure, you could just do it and many patients would not complain, but there will be some who resent it or think the fee is too high. Many will think they should have been advised of the fee. If you or your technicians have to stop your clinical operations to explain a dilation fee every time you want to dilate, you are wasting precious time.
  • Vision plans and medical plans usually include pupil dilation in their definition of a comprehensive eye exam which carries a single fee. In other words, these plans do not allow an extra charge for dilation because they consider it part of the basic service. There is no CPT code for pupil dilation because it is not a test.

Are you charging for the drops or the test?

I think many ECPs who charge extra for dilation are really charging for the detailed fundus exam that they are performing after dilation, more than the actual drops or instillation of the drops. I would use caution with that because ophthalmoscopy is generally considered part of the eye exam, with or without dilation. Extended ophthalmoscopy has its own CPT code (92225) but it has special requirements, such as the existence of a serious medical condition requiring further study and detailed drawings of the retina. Extended ophthalmoscopy should be billed rather infrequently in general eye care practice and frequent use could be a red flag for an audit.

In some practices, the routine is to have most patients return on a different day for dilated fundus examination and that prompts an additional charge. I feel an additional visit is unnecessary. While pupil dilation has a few minor inconveniences for the patient and the office flow, having to return is much more inconvenient.

Are you charging extra to "not dilate"?

It is interesting that some eye care practices charge extra for dilation while others charge extra to not dilate! The "not dilate" fee is actually indirect in that it's positioned as an extra fee for retinal photography or peripheral retinal imaging. Typically the explanation of the retinal imaging test includes some language that implies that opting for it will reduce or eliminate the need to dilate the pupil. Since patients perceive pupil dilation as inconvenient, many will agree to the extra test in order to avoid dilation.

Are you charging to reverse dilation?

Another creative approach that has been used is to charge an extra fee to reverse the dilation quicker. Use of topical drugs such as Dapiprazole have been shown to reduce mydriasis, but not really to reduce the cycloplegia which is the bigger inconvenience and the drops may cause some temporary redness. I don't use these drops very often and when I do I don't charge extra for it.

Do patients refuse dilation often?

Some practices have a high percentage of patients who refuse dilation while others have almost universal acceptance. I don't think the patients are so different but more likely its due to the approach that is used. Patients take their cues from the doctor and staff. If pupil dilation is presented as a procedure that is very inconvenient with vision being blurred for hours, driving will be difficult and the patient is given an option, many will decline. If side effects and risks are dramatized and an informed consent disclaimer is used, more will decline.

I prefer that patients not decline pupil dilation, so I keep the explanation simple. Search the tip archive with key word dilation for more articles on pupil dilation procedures.


Best wishes for continued success,

Read Past Tips Neil B. Gailmard, OD, MBA, FAAO
Editor, Optometric Management Tip of the Week


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Send questions and comments to neil@gailmard.com.

Dr. Gailmard offers consulting services to eye care professionals through Prima Eye Group; information is available at www.primaeyegroup.com.

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