Summary & Overview

HCPCS G8398: Dilated Macular or Fundus Exam Not Performed

HCPCS Level II code G8398 denotes that a dilated macular or fundus examination was not performed during an eye care encounter. Nationally, accurate use of this code matters for clinical documentation, quality measurement, and appropriate billing for ophthalmology and optometry services when dilation could not be completed. Proper coding helps clarify the scope of the visit and supports downstream care coordination and auditing.

Key payers addressed include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find an overview of the code’s clinical context and common reporting scenarios, plus guidance on where to look for benchmarks and policy updates. The publication outlines typical sites of service, the kinds of clinical encounters that generate this code, and the implications for documentation and claim adjudication.

This article offers a concise reference for billing professionals, clinical coders, and practice managers seeking to understand the role of G8398 within outpatient eye care workflows, how it is treated across major payers, and what information is essential for compliant submission. Data not available in the input is clearly noted where applicable.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareG8398HCPCS Level IIophthalmologyeye examfundus exammedical codingbilling complianceoutpatient care

Billing Code Overview

HCPCS Level II code G8398 indicates dilated macular or fundus exam not performed. This code applies to ophthalmology encounters where a dilated examination of the macula or fundus was not completed.

Service type: Eye exam service (dilated macular or fundus exam not performed)
Typical site of service: Ambulatory ophthalmology or optometry clinic, outpatient eye care settings

Data not available in the input.

Clinical & Coding Specifications

Clinical Context

A patient with known diabetic retinopathy or age-related macular degeneration presents for routine ophthalmology follow-up. The clinician plans a dilated macular or fundus exam but documents that the exam was not performed due to factors such as inadequate dilation after pharmacologic drops, severe photophobia or syncopal symptoms with dilation, patient refusal, acute medical instability, or presence of dense media opacity (e.g., dense corneal scar, hyphema) that precludes visualization. The typical workflow: history and reason for visit are documented; visual acuity and external eye exam are completed; dilation drops are instilled when indicated; attempts at indirect ophthalmoscopy or slit-lamp fundus exam are made; when exam cannot be completed the provider documents the reason, documents any alternative assessments (such as undilated retinal imaging if obtained), and bills G8398 to report that the dilated macular or fundus exam was not performed.

Coding Specifications

Modifier	Description	When to Use
`22`	Increased procedural services	Use when work required is substantially greater than typical for attempts to perform the exam (e.g., prolonged attempts, medically complex patient) but the dilated exam still not completed.
`23`	Unusual anesthesia	Use if general anesthesia or monitored anesthesia care was required during attempted exam and contributed to non-performance.
`52`	Reduced services	Use when the dilated fundus exam was partially but not fully completed and the service is reduced.
`53`	Discontinued procedure	Use when the dilated exam was started but terminated due to patient intolerance or acute event.
`54`	Surgical care only	Rarely applicable; use if another clinician bills global surgery and the non-performance relates to postoperative care division.
`55`	Postoperative care only	Use when only postoperative follow-up was provided and a dilated exam was not performed during that visit.
`56`	Preoperative care only	Use when only preoperative evaluation occurred and dilated exam was not completed at that encounter.
`62`	Two surgeons	Use when two surgeons are involved and the non-performance relates to coordination between them.
`AS`	Physician is the primary anesthesiologist	Use when anesthesia services are reported by the operating physician and the exam could not be completed due to anesthesia-related issues.
`CO`	Services for partial hospitalization	Use if the visit is billed under a partial hospitalization program and the dilated exam was not performed for program reasons.

Taxonomy Code	Specialty	Notes
`207W00000X`	Ophthalmology	Primary specialty performing dilated macular/fundus exams.
`207WA0201X`	Retina Specialist	Subspecialist managing macular disease and performing detailed fundus exams.
`207Y00000X`	Optometry	May perform dilated fundus exams and refer when visualization is inadequate.
`261QM0800X`	Anesthesiology	Involved when anesthesia contributes to non-performance or is necessary for exam in special populations.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
Data not available in the input.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`92002`	Ophthalmological services: medical examination and evaluation, new patient; intermediate, with initiation of diagnostic and treatment program; typically without dilation	May be performed when a dilated fundus exam is not completed; documents evaluation of the patient and decision-making.
`92004`	Ophthalmological services: medical examination and evaluation, new patient; comprehensive, with initiation of diagnostic and treatment program; typically with dilation	Often billed when a complete dilated exam is performed; if `G8398` is billed instead, this code would not be reported.
`92012`	Ophthalmological services: established patient; intermediate, with initiation or continuation of diagnostic and treatment program; typically without dilation	Used for follow-up visits when dilation is not performed or not possible.
`92250`	Fundus photography with interpretation and report	May be performed as an alternative when a dilated exam is not possible to document retinal status.
`92227`	Remote imaging for detection of retinal disease (single or limited bilateral image), with report, for diabetic retinal screening	Used when retinal imaging is obtained remotely as an alternative to in-person dilated exam.