How are eye exam codes defined?
CPT includes four codes that specifically describe eye exams:
- 92002: Medical exam and evaluation with initiation of diagnostic and treatment program; intermediate, new patient.
- 92004: Medical exam and evaluation with initiation of diagnostic and treatment program; comprehensive, new patient, one or more visits.
- 92012: Medical exam and evaluation with initiation of diagnostic and treatment program; intermediate, established patient.
- 92014: Medical exam and evaluation with initiation of diagnostic and treatment program; comprehensive, established patient, one or more visits.
Initiation of Diagnostic and Treatment/Management program
According to CPT, it includes “the prescription of medication, and arranging for special ophthalmological diagnostic or treatment services, consultations, laboratory procedures and radiological procedures.” In practice, a diagnostic program involves ordering or performing any diagnostic service that is not part of your eye exam. For example: visual fields, scanning lasers, manifest refractions, or ordering lab or radiology services would constitute initiation of a diagnostic program. Checking visual acuity, measuring IOP or performing a slit lamp exam would not.
Initiating or continuing a treatment program involves providing therapy such as prescriptions, or arranging for treatment or surgery. It may involve educating patients on risk reduction and maintenance, such as diabetic management, or coordinating care with another provider.
General Medical Observation
General medical observations refer to comments in the chart describing the patient’s overall systemic health or general constitution. Commonly we see notes such as: “Patient states she is healthy,” “patient states DM is well controlled,” “patient complains of recent onset of cold symptoms.”
Unlike the E/M coding guidelines, eye exam codes do not specify required history elements. The guidelines simply indicate that a “medical history” is required and leave it up to the provider to document what is appropriate for each patient based on the presenting conditions. It is expected that the history will be commensurate with the patient’s overall health and the presenting conditions.
Both general ophthalmological services (92002-92014) and evaluation and management (E/M) codes (99201-99215) describe office visits for new or established patients. So, when should you apply the ophthalmological services codes rather than the E/M codes?
Generally speaking, ophthalmology services codes focus entirely upon the eye. If the provider is strictly evaluating eye function, report an appropriate code from 92002-92014. Although the eye codes won’t cover every situation, they will suffice for most exams. Revert to the E/M codes for services that don’t fit within the guidelines for eye codes. For complex or very difficult cases, you should use higher-level E/M codes. Similarly, lower level E/M codes will best describe follow-up visits and examinations for uncomplicated problems.