How To Use CPT Code 92004

CPT 92004 is a comprehensive ophthalmological service code for new patients, covering medical examination, evaluation, and initiation of a diagnostic and treatment program. This article will discuss the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, similar codes, and examples of CPT 92004.

1. What is CPT 92004?

CPT 92004 is a code used by medical professionals to bill for comprehensive ophthalmological services provided to new patients. These services include medical examination and evaluation of the eye, as well as the initiation of a diagnostic and treatment program. The code is applicable for one or more visits, depending on the patient’s needs and the provider’s recommendations.

2. 92004 CPT code description

The official description of CPT code 92004 is: “Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; comprehensive, new patient, 1 or more visits.”

3. Procedure

1. The provider takes a detailed patient history, including any existing eye problems or concerns.
2. A comprehensive examination of the eye and adjacent structures is performed, which may include keratometry, routine ophthalmoscopy, retinoscopy, tonometry, or motor evaluation.
3. The provider initiates a diagnostic and treatment program based on the findings of the examination and evaluation.
4. Follow-up visits may be scheduled as needed to monitor the patient’s progress and adjust the treatment plan accordingly.

4. Qualifying circumstances

Patients eligible to receive CPT 92004 services are those who are new to the provider and require a comprehensive ophthalmological evaluation. This may include patients with existing eye problems or those seeking routine eye care. The code is applicable for one or more visits, depending on the patient’s needs and the provider’s recommendations.

5. When to use CPT code 92004

It is appropriate to bill the 92004 CPT code when a provider performs a comprehensive ophthalmological evaluation for a new patient and initiates a diagnostic and treatment program. This may include patients with existing eye problems or those seeking routine eye care. The code is applicable for one or more visits, depending on the patient’s needs and the provider’s recommendations.

6. Documentation requirements

To support a claim for CPT 92004, the following information should be documented:

• Patient’s demographic information, including name, date of birth, and insurance information.
• Reason for the visit, including any existing eye problems or concerns.
• Detailed patient history, including any previous eye treatments or surgeries.
• Results of the comprehensive eye examination and evaluation, including any diagnostic tests performed.
• Diagnosis and treatment plan, including any medications prescribed or procedures recommended.
• Follow-up visit schedule, if applicable.

7. Billing guidelines

When billing for CPT 92004, it is important to follow the appropriate guidelines and rules. Some tips and codes that apply to CPT 92004 include:

• Do not report CPT 92004 in conjunction with 99173, 99174, 99177, or 0469T.
• Be aware that some private payers may only pay for CPT 92004 once per year, as they consider it an annual eye exam.
• Append modifier 25 when the provider performs a significant, separately identifiable evaluation and management service on the same day as the procedure or other service.
• Always report the code that is appropriate for the service provided, which may include E/M codes from 99202 to 99215.

8. Historical information

CPT 92004 was added to the Current Procedural Terminology system on January 1, 1990. The code was changed on January 1, 2009, with the previous descriptor being “Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; comprehensive, new patient, one or more visits.”

9. Similar codes to CPT 92004

Five similar codes to CPT 92004 and how they differentiate are:

• CPT 92002: This code is for intermediate ophthalmological services for new patients, involving a less comprehensive evaluation and treatment program initiation.
• CPT 92012: This code is for intermediate ophthalmological services for established patients, involving the continuation or initiation of a diagnostic and treatment program.
• CPT 92014: This code is for comprehensive ophthalmological services for established patients, involving the continuation or initiation of a diagnostic and treatment program.
• CPT 99202-99215: These codes are for office or other outpatient visits, which may be more appropriate for certain services than eye-specific codes.
• CPT 68761: This code is for closure of the lacrimal punctum by plug insertion, which may be performed in conjunction with CPT 92004 when modifier 25 is appended.

10. Examples

Here are 10 detailed examples of CPT code 92004 procedures:

1. A new patient with a history of glaucoma requires a comprehensive eye examination and evaluation, including tonometry and initiation of a treatment plan.
2. A new patient with diabetes seeks a comprehensive eye examination and evaluation to screen for diabetic retinopathy and initiate a monitoring program.
3. A new patient with a family history of macular degeneration requires a comprehensive eye examination and evaluation, including retinoscopy and initiation of a preventive care plan.
4. A new patient with a history of cataracts requires a comprehensive eye examination and evaluation, including ophthalmoscopy and initiation of a treatment plan.
5. A new patient with a history of strabismus requires a comprehensive eye examination and evaluation, including motor evaluation and initiation of a treatment plan.
6. A new patient with a history of dry eye syndrome requires a comprehensive eye examination and evaluation, including tear film assessment and initiation of a treatment plan.
7. A new patient with a history of corneal dystrophy requires a comprehensive eye examination and evaluation, including keratometry and initiation of a treatment plan.
8. A new patient with a history of retinal detachment requires a comprehensive eye examination and evaluation, including retinoscopy and initiation of a treatment plan.
9. A new patient with a history of uveitis requires a comprehensive eye examination and evaluation, including ophthalmoscopy and initiation of a treatment plan.
10. A new patient with a history of optic neuritis requires a comprehensive eye examination and evaluation, including visual field testing and initiation of a treatment plan.