CPT code 92004 can be used to report a comprehensive ophthalmological examination, a diagnostic and treatment program initiation, and any subsequent required visits for a new patient.
What Is CPT Code 92004?
CPT 92004 describes a comprehensive ophthalmological examination and evaluation of a new patient. This service includes initiating a diagnostic and treatment program and may require one or more visits.
A “comprehensive” examination thoroughly evaluates the patient’s eyes and surrounding structures.
This may include taking a detailed patient history, performing various tests such as keratometry, ophthalmoscopy, retinoscopy, tonometry, and motor evaluations, and beginning a diagnostic and treatment plan that may involve additional diagnostic procedures.
The CPT book describes CPT code 92004 as: “Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; comprehensive, new patient, one or more visits.”
The provider performs a comprehensive ophthalmological evaluation of a new patient, including a thorough examination of the eyes and surrounding structures.
The examination begins with taking a detailed patient history, which helps the provider understand the patient’s current eye health and any previous eye conditions or treatments.
The provider uses various tools and techniques to assess the patient’s eyes during the examination. These may include keratometry, which measures the cornea’s curvature, and routine ophthalmoscopy, which allows the provider to examine the back of the eye.
Retinoscopy can be used to determine the patient’s eyeglass prescription, tonometry and measures the pressure within the eye, and motor evaluation to assess the movement and coordination of the eyes.
After completing the examination, the provider initiates a diagnostic and treatment program for one or more visits.
This may include additional diagnostic procedures, such as imaging or blood tests, to help the provider better understand the patient’s condition.
Based on the examination results and any additional diagnostic tests, the provider will create a treatment plan tailored to the patient’s needs.
This plan may include medication, lifestyle changes, or surgery, depending on the specific condition.
The evaluation may occur over one or more visits and typically entails more diagnostic procedures than an intermediate-level evaluation.
The provider will closely monitor the patient’s progress throughout the treatment program and make adjustments as necessary to ensure the best possible outcome for the patient.
How To Use CPT 92004
CPT code 92004 is used for billing for a comprehensive ophthalmological examination and evaluation for a new patient, including initiating a diagnostic and treatment program, which may require multiple visits.
Do not use CPT 92004 in combination with CPT 99173, CPT 99174, CPT 99177, and CPT 0469T. These codes are used for different ophthalmological evaluations and should not be used together.
You can use CPT code 92002 instead of CPT 92004 when the provider performs an intermediate ophthalmological evaluation on a new patient.
If a patient returns for a dilated follow-up, also known as a dilated fundus examination or DFE, report the provider services, including both days’ work as one unit of a comprehensive ophthalmological examination CPT 92004 or CPT 92014
This is because Medicare has stated that a comprehensive ophthalmological examination may occur in more than one day.
Some private payers may only pay for the CPT 92004 or CPT 92014 codes once per year as they consider these codes annual eye exams.
Some private payers may only pay for CPT 92004 once yearly as they consider it an annual eye exam.
Suppose the provider performs a procedure such as inserting punctual plugs on the same day. In that case, you should append modifier 25 with CPT code 92004.
Some payers may pay for the eye codes without modifier 25 when reported with a procedure or diagnostic service. Still, check that the chart note supports billing 92004 with modifier 25.
The practitioner must prove that the eye code was a significant, separate service from the punctal plug insertion CPT 68761 because every procedure has a small amount of evaluation and management services already built into it.
There is a 10-day global period for punctal plug insertions. Suppose the patient reports improvement later and returns within ten days to have permanent plugs placed.
In that case, you may only bill for the insertion, not a separate office visit, because the plug insertion is the only reason for that visit. However, if the patient returns after ten days, you can bill an E/M or eye code if medical necessity supports the new evaluation and management services.