Summary & Overview
CPT 2023F: Dilated Retinal Exam in Diabetic Patient, No Retinopathy
CPT code 2023F represents a documented dilated retinal eye exam performed by an ophthalmology or optometry provider in a patient with diabetes who has no evidence of diabetic retinopathy. This preventive eye screening code is used to record that a comprehensive dilated retinal exam was completed, interpreted, and charted without findings of retinopathy—information that is relevant for diabetes quality reporting and longitudinal eye care management nationally.
Key payers commonly involved include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise description of clinical context, typical sites of service, and the relevance of documentation for quality measurement. The publication outlines common billing considerations and benchmarking themes, highlights where this code fits in diabetic eye-care workflows, and summarizes policy and payer perspectives that affect national reporting and coverage. The content is intended to help clinical managers, billing staff, and policy analysts understand the code’s purpose, the policy context that shapes its use, and where to look for further payer-specific guidance.
Data not available in the input for associated taxonomies, specific ICD-10 pairings, or related procedure codes.
Billing Code Overview
CPT code 2023F documents a dilated retinal eye exam in a diabetic patient with no evidence of diabetic retinopathy. The ophthalmology or optometry provider performs the dilated retinal examination, interprets the findings, and records the results in the patient’s chart.
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Service type: Dilated retinal examination for diabetic eye screening
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Typical site of service: Ophthalmology clinic or optometry office
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.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
00 | Modifier not provided / no additional information | Use when no specific billing modifier applies and the claim requires a default or placeholder modifier; follows payer rules for required modifier fields. |
ET | Eligible Telemedicine or telehealth modifier (per some payer-specific uses) | Use when elements of the visit are delivered via an approved telehealth platform and the payer accepts for tele-ophthalmology components as allowed.