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    v1.0.28
    OpenPayerBilling CodesProcedures / Professional ServicesHCPCS hcpcs-g8397-dilated-macular-fundus-exam-macular-edema-retinopathy-severity
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    HCPCS G8397: Dilated Macular or Fundus Exam, Macular Edema and Retinopathy

    HCPCS Level II code G8397 describes a dilated macular or fundus examination performed with documentation of the presence or absence of macular edema and the level of severity of retinopathy; this is an ophthalmic diagnostic clinical exam service typically provided in an outpatient ophthalmology or retina clinic setting and involves a comprehensive dilated retinal evaluation focused on the macula and posterior pole.

    For related coverage guidance, see recent payer policy updates: Esophagogastroduodenoscopy (EGD) Coverage Policy, Magnetic Sphincter Augmentation for the Treatment of Gastroesophageal Reflux Disease (GERD), Fecal Analysis in the Diagnosis of Intestinal Dysbiosis and Fecal Microbiota Transplant Testing.

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    Clinical & Coding Specifications

    Clinical Context

    A 58-year-old patient with a history of type 2 diabetes mellitus presents for a dilated macular and fundus examination to evaluate for diabetic retinopathy and macular edema. The clinic workflow begins with patient intake and documentation of visual symptoms (blurry central vision, metamorphopsia, or decreased acuity). An ophthalmic technician performs preliminary visual acuity, intraocular pressure, and dilation with mydriatic drops. The ophthalmologist or retina specialist then performs a comprehensive dilated fundus examination using slit-lamp biomicroscopy with a contact or non‑contact lens and indirect ophthalmoscopy to inspect the macula and peripheral retina. Findings are documented explicitly, including the presence or absence of macular edema, level of severity of retinopathy (none, mild, moderate, severe nonproliferative, or proliferative), and any additional observations (hard exudates, microaneurysms, neovascularization, vitreous hemorrhage). Imaging such as optical coherence tomography (OCT) or fundus photography may be ordered and performed before or after the dilated exam to quantify macular thickness and correlate structural changes. The visit note includes clinical decision-making about follow-up interval, need for intravitreal therapy, laser therapy referral, or urgent intervention if proliferative disease is suspected. Accurate documentation of the dilated macular or fundus exam findings and severity staging supports use of billing code G8397 and informs subsequent diagnostic or therapeutic procedures.

    Related CPT Codes

    CPT CodeDescriptionRelationship to This Procedure
    92250Fundus photography with interpretation and reportOften performed to document retinal appearance and track progression alongside a dilated fundus exam.
    92134Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report; unilateral or bilateral (OCT)Performed to evaluate and quantify macular edema and retinal thickness following or in conjunction with the dilated exam.
    67028Intravitreal injection of a pharmacologic agent (separate procedure)May be performed after diagnosis of clinically significant macular edema requiring pharmacologic therapy.
    67228Panretinal photocoagulation, therapeutic; 1 or more sessionsPerformed when proliferative diabetic retinopathy is identified on dilated exam and requires laser therapy.
    92012Ophthalmological services: intermediate, established patient; with retina-focused slit-lamp or instrumentation (without dilation)May be used for follow-up visits focused on retinal status when dilation is not performed.
    92136Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report; unilateral or bilateral, with remote analysis for screeningUsed in telemedicine or screening workflows to supplement a dilated exam.

    Related Modifiers

    8 rows

    ModifierDescriptionWhen to Use
    22Modifier –22 (Increased Procedural Services) is used when a reported procedure is substantially more extensive than normally required. The CPT Manual and CMS state it may be appended only when the…- When to use: Append modifier -22 to a procedural CPT code when the service performed is substantially more extensive than the usual service described by that code — i.e., the procedure required…
    23Modifier -23 (Unusual Anesthesia) is used on anesthesia service CPT codes when a procedure that normally requires no anesthesia or only local anesthesia must be performed under general anesthesia…- Use modifier -23 only on anesthesia CPT codes (00100–01999) when a procedure that normally requires no anesthesia or only local anesthesia must be performed under general anesthesia because of…
    52Modifier ‑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…
    53Modifier 53 (Discontinued Procedure) signals that a surgical or diagnostic service was begun by the physician but terminated because of extenuating circumstances that threatened the patient’s…- Use modifier -53 when a physician/qualified healthcare professional has started a surgical or diagnostic procedure (e.g., anesthesia administered, incision or scope insertion) and then discontinues…
    54Modifier ‑54 (“Surgical care only”) is appended to a CPT surgical procedure when the reporting surgeon performs the intraoperative (surgical) component but does not furnish the preoperative and/or…- Use modifier -54 when the reporting surgeon provided only the intraoperative (surgical) component of a procedure and preoperative and/or postoperative management has been or will be provided by…
    55Modifier –55 indicates the billing provider furnished only postoperative management for a procedure that has a global surgical period. According to AAPC, this modifier is appended to the same CPT…- Use modifier -55 when billing the same CPT surgical code that has a 10- or 90-day global period and you, as a provider other than the original surgeon, furnished ONLY postoperative management (no…
    56Modifier ‑56 indicates the reporting provider furnished only the preoperative management for a surgical procedure and did not perform the intraoperative or postoperative care. It is used in…- Use Modifier -56 when a provider performs only the preoperative management in a split‑care situation (one physician manages preop care while a different physician performs the intraoperative…
    62Modifier 62 indicates that two surgeons function as co‑surgeons, each performing distinct parts of the same primary surgical procedure. It is appended to the primary procedure code (and any…- Use modifier -62 when two surgeons act as co‑surgeons (both primary surgeons) on a single definitive primary procedure, each performing distinct parts of the same surgical procedure (append -62 to…

    Related Provider Taxonomies

    8 rows

    Taxonomy CodeSpecialtyNotes
    207W00000XOphthalmology PhysicianAn ophthalmologist has the knowledge and professional skills needed to provide comprehensive eye and vision care. Ophthalmologists are medically train…
    363A00000XPhysician AssistantA physician assistant is a person who has successfully completed an accredited education program for physician assistant, is licensed by the state and…
    2084P0800XPsychiatry PhysicianA Psychiatrist specializes in the prevention, diagnosis, and treatment of mental disorders, emotional disorders, psychotic disorders, mood disorders, …
    2279H0200XHome Health Registered Respiratory TherapistHome care fosters individual responsibility for self-management of chronic respiratory conditions. It includes individualized assessment based plans …
    2084N0600XClinical Neurophysiology PhysicianClinical Neurophysiology is a subspecialty with psychiatric or neurologic expertise in the diagnosis and management of central, peripheral, and autono…
    2083P0500XPreventive Medicine/Occupational Environmental Medicine PhysicianA preventive medicine physician who specializes in preventive medicine/occupational-environmental medicine, which is focused on protecting the populat…
    3418M1130XMilitary or U.S. Coast Guard Water Transport AmbulanceVehicle and staff for patient emergency or non-emergency sea/water transport
    246ZB0500XBiochemistTechnologists, Technicians & Other Technical Service Providers · Specialist/Technologist, Other

    Related Payer Policy Updates

    Specialty: Gastroenterology1 / 3

    7 rows

    PolicyPayerEffective Date
    Esophagogastroduodenoscopy (EGD) Coverage Policyevicore2026-11-05
    Magnetic Sphincter Augmentation for the Treatment of Gastroesophageal Reflux Disease (GERD)univerahealthcare2026-10-15
    Fecal Analysis in the Diagnosis of Intestinal Dysbiosis and Fecal Microbiota Transplant TestingOscar Health2026-10-01
    Serum Testing for Hepatic Fibrosis in the Evaluation and Monitoring of Chronic Liver DiseaseOscar Health2026-10-01
    Pancreatic Enzyme Testing for Acute PancreatitisOscar Health2026-10-01
    Helicobacter pylori TestingOscar Health2026-10-01
    Celiac Disease TestingOscar Health2026-10-01

    Related Codes

    HCPCS-G9490-HOME-ASSESSMENT-NON-HOMEBOUND

    HCPCS G9490: Home Visit Patient Assessment for Non-Homebound Beneficiary

    HCPCS-G0008-INFLUENZA-VACCINE-ADMINISTRATION

    HCPCS G0008: Administration of Influenza Virus Vaccine

    HCPCS-G0009-PNEUMOCOCCAL-VACCINE-ADMINISTRATION

    HCPCS G0009: Administration of Pneumococcal Vaccine

    HCPCS-G0010-HEPATITIS-B-VACCINE-ADMINISTRATION

    HCPCS G0010: Administration of Hepatitis B Vaccine

    HCPCS-G0011-PREP-COUNSELING-HIV-RISK-REDUCTION-ADHERENCE

    HCPCS G0011: Individual PrEP Counseling, HIV Risk Assessment

    HCPCS-G0012-PRE-EXPOSURE-PROPHYLAXIS-INJECTION-HIV-PREVENTION

    HCPCS G0012: Injection of PrEP Drug for HIV Prevention

    HCPCS-G0013-PREP-INDIVIDUAL-COUNSELING-HIV-RISK-REDUCTION

    HCPCS G0013: Individual PrEP Counseling by Clinical Staff

    HCPCS-G0017-PSYCHOTHERAPY-CRISIS-FIRST-60-MINUTES-NON-OFFICE

    HCPCS G0017: Psychotherapy for Crisis, First 60 Minutes

    HCPCS-G0018-PSYCHOTHERAPY-CRISIS-ADDITIONAL-30-MINUTES-NON-OFFICE

    HCPCS G0018: Psychotherapy for Crisis, Additional 30 Minutes

    HCPCS-G0019-COMMUNITY-HEALTH-INTEGRATION-SDOH-CARE-COORDINATION

    HCPCS G0019: Community Health Integration, Person-Centered Assessment

    Showing 1–10 of 1996

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    Frequently Asked Questions

    References

    1. 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. 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. 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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