CPT 2023F: Dilated Retinal Eye Exam for Diabetic Patient, No Retinopathy

CPT code 2023F describes a dilated retinal eye exam performed by an ophthalmology or optometry provider in a patient with diabetes with no evidence of diabetic retinopathy, with the provider interpreting and documenting the findings; service type: dilated retinal examination; typical site of service: ophthalmology or optometry clinic/office.

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CPT 2023F: Dilated Retinal Eye Exam for Diabetic Patient, No Retinopathy

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Clinical & Coding Specifications

Clinical Context

A 58-year-old patient with a long-standing diagnosis of type 2 diabetes mellitus presents for an annual diabetic eye exam. The ophthalmology provider performs a dilated retinal exam using pharmacologic mydriasis and a slit-lamp biomicroscope with indirect ophthalmoscopy to evaluate the retina and optic nerve for diabetic retinopathy. There is no evidence of microaneurysms, hemorrhages, exudates, neovascularization, or macular edema. The clinician documents lens status, pupil response, intraocular pressure as indicated, fundus findings for each eye, and the interpretation of no diabetic retinopathy in the chart. The service is coded as 2023F to reflect a dilated retinal exam in a diabetic patient with no evidence of diabetic retinopathy. Typical site of service is an outpatient ophthalmology or optometry clinic; the workflow includes intake, dilation, examination, documentation, and counseling regarding interval surveillance and return precautions.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`92014`	Ophthalmological examination and evaluation, established patient, with dilation, extended ophthalmoscopy and interpretation and report, for evaluation and management of retinal disease; typically includes fundus photography or extended exam	Often performed for more detailed retinal evaluation when pathology is suspected or when additional documentation beyond a screening `2023F` is needed.

92250 | Fundus photography with interpretation and report | Performed alongside a dilated exam to document retinal status photographically for baseline or progression comparisons.

92134 | Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report (OCT), unilateral or bilateral | Used when macular edema or subtle retinal changes require optical coherence tomography for diagnosis or monitoring beyond the screening exam.

99213 | Office or other outpatient visit for the evaluation and management of an established patient, typically 15 minutes | Commonly billed the same day when a medically necessary E/M service is provided in addition to the dilated retinal exam; may require modifier 25.

CPT not provided | Data not available in the input. | Data not available in the input.

Related Modifiers

5 rows

Modifier	Description	When to Use
25	CPT modifier 25 indicates that on the same day as another procedure or service, the same physician or other qualified health care professional provided a significant, separately identifiable…	- When to apply: Use modifier 25 only on an E/M code to indicate the same provider delivered a significant, separately identifiable E/M service on the same day as another procedure or service — i.e.,…
59	Modifier 59 indicates a distinct procedural service when two procedures that are not normally billed together are clinically and procedurally separate. The CPT definition (as reiterated by CMS)…	- Use modifier -59 to report a distinct procedural service when documentation supports that the procedure reported is not normally billed together with another service on the same day because of a…
57	CPT® modifier -57 (“Decision for Surgery”) is appended to an Evaluation and Management (E/M) service when that encounter results in the initial decision to perform a major surgery (a procedure with a…	- Use modifier 57 when an E/M service provided by the same provider (or same tax ID) on the day of or the day before a major surgical procedure (90‑day global period) results in the initial decision…
52	Modifier ‑52 (Reduced Services) indicates that a service or procedure was partially reduced or omitted at the provider’s discretion, allowing reporting of the basic procedure number with a qualifier…	- Use modifier -52 when a physician or qualified health professional electively reduces or omits part of a procedure or service (for example, performing fewer required views or omitting a portion of…
26	Modifier 26 (Professional Component) identifies and bills only the professional portion of a split service — the physician’s interpretation, report, and medical judgment — when the technical…	- Use CPT Modifier -26 when you are billing only the professional component (PC) of a split‑bill eligible service—i.e., you performed the physician interpretation, medical judgment and prepared a…

Related Provider Taxonomies

8 rows

Taxonomy Code	Specialty	Notes
207W00000X	Ophthalmology Physician	An ophthalmologist has the knowledge and professional skills needed to provide comprehensive eye and vision care. Ophthalmologists are medically train…
207Y00000X	Otolaryngology Physician	An otolaryngologist-head and neck surgeon provides comprehensive medical and surgical care for patients with diseases and disorders that affect the ea…
363L00000X	Nurse Practitioner	(1) A registered nurse provider with a graduate degree in nursing prepared for advanced practice involving independent and interdependent decision mak…
207P00000X	Emergency Medicine Physician	An emergency physician focuses on the immediate decision making and action necessary to prevent death or any further disability both in the pre-hospit…
341800000X	Military/U.S. Coast Guard Transport	Transportation Services · Military/U.S. Coast Guard Transport
208G00000X	Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician	A thoracic surgeon provides the operative, perioperative and critical care of patients with pathologic conditions within the chest. Included is the su…
364SI0800X	Informatics Clinical Nurse Specialist	Physician Assistants & Advanced Practice Nursing Providers · Clinical Nurse Specialist
3336M0002X	Mail Order Pharmacy	A pharmacy where pharmacists compound or dispense prescriptions or other medications in accordance with federal and state law, using common carriers t…

Related Codes

CPT-2000F-UNDEFINED-SERVICE

CPT 2000F: No Summary found

CPT-2001F-UNSPECIFIED-CLINICAL-SERVICE

CPT 2001F: No Summary Available

CPT-2002F-UNSPECIFIED-SERVICE

CPT 2002F: No Summary found for this code

CPT-2004F-UNDEFINED-SERVICE

CPT 2004F: Clinical/Quality Measure (No Summary Available)

CPT-2010F-UNSPECIFIED-SERVICE

CPT 2010F: No Summary found for this code

CPT-2014F-NO-SUMMARY-AVAILABLE

CPT 2014F: Short-interval Oxygen Saturation Assessment

CPT-2015F-ASTHMA-CONTROL-ASSESSMENT

CPT 2015F: Asthma Control Assessment and Documentation

CPT-2016F-ASTHMA-RISK-ASSESSMENT-AND-DOCUMENTATION

CPT 2016F: Asthma Risk Assessment and Documentation

CPT-2018F-UNDEFINED-SERVICE

CPT 2018F: No Summary Found

CPT-2019F-UNDEFINED-SERVICE

CPT 2019F: Procedure, specific descriptor unavailable

Showing 1–10 of 27

Frequently Asked Questions

References

1.CPT® Codes and Descriptions. AAPC. Retrieved Aug 11, 2026.Maintains the CPT code set's official descriptions and guidelines, licensed from the American Medical Association, used as the definitional source for CPT codes on this page.
2.HCPCS Quarterly Update. Centers for Medicare & Medicaid Services (CMS). Retrieved Aug 11, 2026.CMS's quarterly release of HCPCS Level II codes and short/long descriptors, the source for HCPCS code definitions and update history.
3.ICD-10-CM Full Code List. Centers for Medicare & Medicaid Services (CMS). Retrieved Aug 11, 2026.CMS's complete ICD-10-CM diagnosis code list, used to cross-reference diagnosis codes associated with this procedure or service.

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Clinical & Coding Specifications

Clinical Context

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`92014`	Ophthalmological examination and evaluation, established patient, with dilation, extended ophthalmoscopy and interpretation and report, for evaluation and management of retinal disease; typically includes fundus photography or extended exam	Often performed for more detailed retinal evaluation when pathology is suspected or when additional documentation beyond a screening `2023F` is needed.

92250 | Fundus photography with interpretation and report | Performed alongside a dilated exam to document retinal status photographically for baseline or progression comparisons.

CPT not provided | Data not available in the input. | Data not available in the input.

Related Modifiers

5 rows

Modifier	Description	When to Use
25	CPT modifier 25 indicates that on the same day as another procedure or service, the same physician or other qualified health care professional provided a significant, separately identifiable…	- When to apply: Use modifier 25 only on an E/M code to indicate the same provider delivered a significant, separately identifiable E/M service on the same day as another procedure or service — i.e.,…
59	Modifier 59 indicates a distinct procedural service when two procedures that are not normally billed together are clinically and procedurally separate. The CPT definition (as reiterated by CMS)…	- Use modifier -59 to report a distinct procedural service when documentation supports that the procedure reported is not normally billed together with another service on the same day because of a…
57	CPT® modifier -57 (“Decision for Surgery”) is appended to an Evaluation and Management (E/M) service when that encounter results in the initial decision to perform a major surgery (a procedure with a…	- Use modifier 57 when an E/M service provided by the same provider (or same tax ID) on the day of or the day before a major surgical procedure (90‑day global period) results in the initial decision…
52	Modifier ‑52 (Reduced Services) indicates that a service or procedure was partially reduced or omitted at the provider’s discretion, allowing reporting of the basic procedure number with a qualifier…	- Use modifier -52 when a physician or qualified health professional electively reduces or omits part of a procedure or service (for example, performing fewer required views or omitting a portion of…
26	Modifier 26 (Professional Component) identifies and bills only the professional portion of a split service — the physician’s interpretation, report, and medical judgment — when the technical…	- Use CPT Modifier -26 when you are billing only the professional component (PC) of a split‑bill eligible service—i.e., you performed the physician interpretation, medical judgment and prepared a…

Related Provider Taxonomies

8 rows

Taxonomy Code	Specialty	Notes
207W00000X	Ophthalmology Physician	An ophthalmologist has the knowledge and professional skills needed to provide comprehensive eye and vision care. Ophthalmologists are medically train…
207Y00000X	Otolaryngology Physician	An otolaryngologist-head and neck surgeon provides comprehensive medical and surgical care for patients with diseases and disorders that affect the ea…
363L00000X	Nurse Practitioner	(1) A registered nurse provider with a graduate degree in nursing prepared for advanced practice involving independent and interdependent decision mak…
207P00000X	Emergency Medicine Physician	An emergency physician focuses on the immediate decision making and action necessary to prevent death or any further disability both in the pre-hospit…
341800000X	Military/U.S. Coast Guard Transport	Transportation Services · Military/U.S. Coast Guard Transport
208G00000X	Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician	A thoracic surgeon provides the operative, perioperative and critical care of patients with pathologic conditions within the chest. Included is the su…
364SI0800X	Informatics Clinical Nurse Specialist	Physician Assistants & Advanced Practice Nursing Providers · Clinical Nurse Specialist
3336M0002X	Mail Order Pharmacy	A pharmacy where pharmacists compound or dispense prescriptions or other medications in accordance with federal and state law, using common carriers t…

Related Codes

CPT-2000F-UNDEFINED-SERVICE

CPT 2000F: No Summary found

CPT-2001F-UNSPECIFIED-CLINICAL-SERVICE

CPT 2001F: No Summary Available

CPT-2002F-UNSPECIFIED-SERVICE

CPT 2002F: No Summary found for this code

CPT-2004F-UNDEFINED-SERVICE

CPT 2004F: Clinical/Quality Measure (No Summary Available)

CPT-2010F-UNSPECIFIED-SERVICE

CPT 2010F: No Summary found for this code

CPT-2014F-NO-SUMMARY-AVAILABLE

CPT 2014F: Short-interval Oxygen Saturation Assessment

CPT-2015F-ASTHMA-CONTROL-ASSESSMENT

CPT 2015F: Asthma Control Assessment and Documentation

CPT-2016F-ASTHMA-RISK-ASSESSMENT-AND-DOCUMENTATION

CPT 2016F: Asthma Risk Assessment and Documentation

CPT-2018F-UNDEFINED-SERVICE

CPT 2018F: No Summary Found

CPT-2019F-UNDEFINED-SERVICE

CPT 2019F: Procedure, specific descriptor unavailable

Showing 1–10 of 27

Frequently Asked Questions

References

1.CPT® Codes and Descriptions. AAPC. Retrieved Aug 11, 2026.Maintains the CPT code set's official descriptions and guidelines, licensed from the American Medical Association, used as the definitional source for CPT codes on this page.
2.HCPCS Quarterly Update. Centers for Medicare & Medicaid Services (CMS). Retrieved Aug 11, 2026.CMS's quarterly release of HCPCS Level II codes and short/long descriptors, the source for HCPCS code definitions and update history.
3.ICD-10-CM Full Code List. Centers for Medicare & Medicaid Services (CMS). Retrieved Aug 11, 2026.CMS's complete ICD-10-CM diagnosis code list, used to cross-reference diagnosis codes associated with this procedure or service.

Published by

Trek Health powers OpenPayer with a leading commercial payer intelligence platform, seamlessly converting fragmented payer data into actionable insights for provider organizations.

CPT 2023F: Dilated Retinal Eye Exam for Diabetic Patient, No Retinopathy

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CPT 2023F: Dilated Retinal Eye Exam for Diabetic Patient, No Retinopathy

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Clinical & Coding Specifications

Clinical Context

Related CPT Codes

Related Modifiers

Related Provider Taxonomies

Related Codes

What does CPT code 2023F represent?

Where is this service typically performed and what does the workflow include?

When might additional CPT codes be billed alongside or instead of 2023F?

Which diagnoses commonly support billing of 2023F?

Which payers are listed as covered in the summary metadata for this code?

References

Clinical & Coding Specifications

Clinical Context

Related CPT Codes

Related Modifiers

Related Provider Taxonomies

Related Codes

What does CPT code 2023F represent?

Where is this service typically performed and what does the workflow include?

When might additional CPT codes be billed alongside or instead of 2023F?

Which diagnoses commonly support billing of 2023F?

Which payers are listed as covered in the summary metadata for this code?

References