How To Use CPT Code 92018

CPT 92018 describes the examination and evaluation of the eye while the patient is under general anesthesia. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, similar codes and billing examples.

1. What is CPT Code 92018?

CPT 92018 can be used to describe the ophthalmological examination and evaluation of the eye while the patient is asleep under general anesthesia. This code encompasses a detailed examination of the internal structure of the eye, as well as tests to assess the eyeball’s ability to move passively or with manipulation by the physician. The purpose of this procedure is to facilitate a comprehensive diagnostic examination of the eye.

2. Official Description

The official description of CPT code 92018 is: ‘Ophthalmological examination and evaluation, under general anesthesia, with or without manipulation of globe for passive range of motion or other manipulation to facilitate diagnostic examination; complete.’

3. Procedure

1. During the procedure, the patient is placed under general anesthesia to ensure they are asleep and comfortable.
2. The ophthalmologist performs a detailed examination of the internal aspects of the eye, known as a fundoscopic examination, to assess for conditions such as glaucoma, retinal abnormalities, or tumors.
3. Special measurements of the eye may be taken, and ultrasound examination may be performed to gather additional diagnostic information.
4. The physician may manipulate the eyeball directly by pulling on the individual muscles controlling eye movement to assess the eye’s ability to move and detect any mechanical obstructions.
5. Pictures of the internal components of the eye may be taken to aid in diagnosis and treatment planning.
6. Treatment of various eye conditions may be performed during the procedure, if necessary.

4. Qualifying circumstances

CPT 92018 is typically performed on children or uncooperative adults who cannot undergo a detailed eye examination while awake. The use of general anesthesia allows the physician to thoroughly evaluate the internal and external aspects of the eye, including the movement of the eyeball. This procedure is essential for diagnosing conditions such as glaucoma, retinal abnormalities, tumors, and mechanical obstructions to eye movement.

5. When to use CPT code 92018

CPT code 92018 should be used when an ophthalmological examination and evaluation of the eye is performed under general anesthesia. This code is appropriate when the patient is unable to cooperate or when a detailed examination of the eye cannot be performed while awake. It is important to note that CPT code 92018 should not be reported with other payable eye surgery codes unless an appropriate modifier is used.

6. Documentation requirements

To support a claim for CPT code 92018, the following documentation is required:

• Documentation of the patient’s need for an ophthalmological examination under general anesthesia
• Details of the examination performed, including the internal and external aspects of the eye
• Any tests or measurements taken during the procedure
• Documentation of any treatment performed
• Signature of the performing physician

7. Billing guidelines

When billing for CPT code 92018, ensure that the procedure is performed under general anesthesia and includes a comprehensive examination and evaluation of the eye. It is important to note that CPT code 92018 should not be reported with other payable eye surgery codes without an appropriate modifier. It is recommended to review the specific guidelines provided by the payer to ensure accurate billing and reimbursement.

8. Historical information

CPT code 92018 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates or changes to the code since its addition.

9. Examples

1. A child undergoing an ophthalmological examination and evaluation under general anesthesia to assess for retinal abnormalities.
2. An uncooperative adult receiving a comprehensive eye examination while asleep under general anesthesia to diagnose glaucoma.
3. A patient with suspected eye tumors undergoing a detailed examination of the internal aspects of the eye under general anesthesia.
4. An individual with double vision or strabismus undergoing an evaluation of eye movement while asleep under general anesthesia to determine if there are mechanical obstructions.
5. A patient requiring treatment for a specific eye condition, such as retinal detachment, during an ophthalmological examination under general anesthesia.
6. A child with a history of uncooperative behavior during eye examinations undergoing a comprehensive evaluation of the eye while asleep under general anesthesia.
7. An adult with limited mobility undergoing an ophthalmological examination under general anesthesia to assess for retinal abnormalities.
8. A patient with suspected glaucoma undergoing a detailed examination of the internal aspects of the eye under general anesthesia.
9. An individual with a history of eye tumors undergoing a comprehensive evaluation of the eye while asleep under general anesthesia.
10. A patient with strabismus undergoing an evaluation of eye movement while asleep under general anesthesia to determine the cause of the condition.