92014 vs 99214: Eye Codes vs E/M Codes — Which One to Bill (12 Worked Exam Examples)
Quick answer. Bill CPT 92014 when an established patient receives a comprehensive evaluation of the visual system with all required elements and a diagnostic and treatment program. Bill CPT 99214 when the visit is driven by managing a medical problem and the documented medical decision-making is moderate (or total time is 30–39 minutes). The chief complaint decides the code family; the documentation decides the level.
Last reviewed: August 29, 2026 · Jelo Editorial Team
Optometry is the only specialty that gets to choose between two complete code sets for the same office visit: the ophthalmological service codes (92002, 92004, 92012, 92014) and the office E/M codes (99202–99215). That choice is where most under-coding, over-coding, and avoidable denials in an eye-care practice come from. This guide is a decision tool, not a definition page. If you want the descriptors alone, the leaf pages for CPT 92014 and CPT 99214 have them; the rest of this post is about picking the right one, fast, on a real patient.
The 30-second rule: the chief complaint drives the code family
The 30-second rule: read the chief complaint and ask which of two things the visit is. If the patient needs an evaluation of the visual system (acuity, refraction, external, internal, fields, motility) and you will start or continue a plan, the visit belongs in the eye codes (920xx). If the patient needs a medical problem managed, and the work is dominated by history, data review, and decisions about risk, the visit belongs in the E/M codes (992xx). Level comes later; family comes first.
Two examples of the rule in action. "I need my eyes checked, my glasses feel off, and my mom has glaucoma" is an evaluation of the visual system with a treatment plan (new refraction, baseline IOP and fields): eye code. "My diabetes doctor sent me, my sugars have been running high, and I reviewed the OCT you ordered" is management of a systemic disease with data and risk: E/M code. The same chair, the same doctor, the same 25 minutes, two different code families.
The reason the rule works is that the two code sets are graded on different things. Eye codes are graded on what was examined — a checklist of elements. E/M codes since the 2021 AMA revision are graded on what was decided — the number and complexity of problems, the data reviewed, and the risk of management. A comprehensive exam with a trivial decision is an eye code. A ten-minute exam with a complex decision is an E/M. If you find yourself trying to get an E/M level out of a long exam element list, or an eye code out of a heavy data-review visit, you are in the wrong family.
92014 vs 99214 side-by-side
CPT 92014 and CPT 99214 both describe an established-patient office visit, but 92014 is earned by performing every comprehensive ophthalmological element and setting a diagnostic and treatment program, while 99214 is earned by moderate medical decision-making or 30–39 minutes of total time on the date of service. Their 2026 Medicare national non-facility rates overlap, so the correct code is the one the documentation supports, not the one that pays more.
| Dimension | CPT 92014 (comprehensive eye exam, established) | CPT 99214 (office E/M, established, moderate) |
|---|---|---|
| What earns the code | All comprehensive elements documented: history, general medical observation, external exam, internal (ophthalmoscopic) exam, gross visual fields, basic sensorimotor exam; plus initiation or continuation of a diagnostic and treatment program. Dilation, or documented reason not to dilate, is expected by most payers. | Moderate MDM in 2 of 3 columns (problems, data, risk), or 30–39 minutes of total physician time on the date of the visit under the 2021 AMA guidelines. |
| Typical chief complaint | "Eye exam," blurred vision, new glasses, baseline for glaucoma suspect, diabetic annual dilated exam. | Flare of a chronic condition, new symptom with work-up, medication change, review of OCT/VF results with a management decision. |
| 2026 Medicare national non-facility rate (approximate) | $95–$135 | $125–$140 |
| Related new-patient code | 92004 ($120–$165 approx.) | 99204 (moderate MDM) / 99203 (low MDM, $105–$120 approx.) |
| Related lower level | 92012 intermediate ($60–$85 approx.) | 99213 low MDM ($90–$100 approx.) |
| Payer | Medical insurance with a medical diagnosis; vision plans pay the routine benefit (often reported with 92014 or S0621 and including refraction). | Medical insurance only. Vision plans do not reimburse E/M codes. |
| Refraction | 92015 on a separate line; -GY to Medicare, collect from patient. | 92015 on a separate line if performed; same Medicare rule. |
| Frequency | No universal Medicare limit, but medical necessity for a comprehensive service must be evident each time; many MACs question more than one per year without a new problem. | No frequency limit; each visit stands on its own MDM. |
| Time-based option | None. Time does not level an eye code. | Yes: 30–39 minutes total time (pre-visit review, face-to-face, documentation, coordination) on the date of service. |
The rates above are national approximations for 2026 and vary by locality, payer and contract. Verify on the CMS Physician Fee Schedule lookup and confirm the E/M levelling rules in the AMA 2021 office E/M guidelines. For what vision plans actually pay against these codes, see VSP vs EyeMed reimbursement 2026.
What is the difference between 92014 and 99214?
CPT 92014 is a comprehensive ophthalmological service for an established patient and requires every comprehensive exam element plus a diagnostic and treatment program. CPT 99214 is an established-patient office E/M visit selected by moderate medical decision-making or 30–39 minutes of total time. Bill 92014 when the visit is a full evaluation of the visual system; bill 99214 when the visit is about managing a medical problem, reviewing data, and risk.
12 exam scenarios → the right code
Every scenario below runs through the 30-second rule first (family), then the documentation (level). The "why" column is the sentence you would put in the note if a payer asked. These are illustrative encounters; the code that applies to your patient depends on what you actually documented.
| # | Scenario | Code | Why |
|---|---|---|---|
| 1 | Established patient, "annual exam," family history of glaucoma, IOP 23/24, C/D 0.6 — you order baseline OCT and fields. | 92014 (+ 92015) | Full visual-system evaluation with initiation of a diagnostic program (glaucoma suspect work-up). Comprehensive elements documented. Bill to medical with H40.013/H40.019 as the primary dx; refraction to the vision plan or patient. |
| 2 | Type 2 diabetic, annual dilated exam requested by PCP, no retinopathy found, letter sent to PCP. | 92014 | Comprehensive exam with dilated fundus, continuation of a monitoring program. E11.9 to medical. A negative finding does not lower the exam level. |
| 3 | New patient, red, watery eye for two days, focused slit-lamp exam, viral conjunctivitis, supportive care. | 92002 or 99202/99203 | Problem-focused, not comprehensive. Either family fits; the intermediate eye code is simplest. If you review outside records or prescribe, low MDM supports 99203. |
| 4 | Established patient, painful red eye, photophobia, cells and flare in the AC — anterior uveitis, steroid drops started, labs ordered. | 99214 | A new problem with uncertain prognosis, prescription drug management, and ordering tests — moderate MDM. The visit is about a medical decision, not a system evaluation. |
| 5 | Established patient, comprehensive exam plus a new soft toric contact-lens fitting with trial lenses and training. | 92014 + 92310 (+ 92015) | The exam is comprehensive; the fitting is a separately reportable service. Vision plan pays the routine exam and the CL benefit; document the fitting elements separately. |
| 6 | New patient, gradual blur at distance and night glare, nuclear cataracts grade 2 OU, best-corrected 20/40, referred for surgical consult. | 92004 (+ 92015) | New patient, comprehensive elements, initiation of a treatment program (referral). H25.13 to medical. If the visit were dominated by counselling and coordination and you documented 45+ minutes, 99204 is defensible; the exam-driven visit is the eye code. |
| 7 | Established dry-eye patient, worsening despite lubricants, MGD graded, you decide on punctal plugs today and prescribe cyclosporine. | 99214 (+ 68761 for the plugs, E/M with -25) | Chronic illness with progression plus prescription drug management: moderate MDM. The plug insertion is a procedure; append -25 to the E/M only if the E/M is significant and separately identifiable from the procedure decision. |
| 8 | Post-op day 7 cataract co-management visit inside the global period, IOP and wound check. | No exam code — 66984 with -55 | Post-operative care within the global is billed as the surgical code with modifier -55 for the co-managing OD, not 92012 or 99213. Billing an exam code inside the global is a routine CO-97 denial. |
| 9 | Established patient, metallic foreign body on the cornea, removed at the slit lamp, antibiotic prescribed. | 65222 (procedure); E/M only with -25 if separate | The removal is the service. A separate E/M is billable only if a distinct problem was evaluated beyond the decision to remove the foreign body. |
| 10 | Six-year-old, first eye exam, school screening failure, cycloplegic refraction, mild hyperopia, glasses prescribed. | 92004 (+ 92015) | New patient, comprehensive elements adapted to age (sensorimotor and fields documented), treatment program started. Most vision plans and Medicaid pay this as the routine pediatric exam. |
| 11 | Established POAG patient on latanoprost, IOP at target, you independently interpret today's OCT RNFL and 24-2 field, continue therapy, 6-month recall. | 99214 (+ 92133, 92083) | Chronic illness plus independent interpretation of two tests plus prescription drug management: moderate MDM. A comprehensive eye exam was not performed, so 92014 does not fit even though the visit is "about the eyes." |
| 12 | Telehealth video follow-up for a resolving corneal abrasion, symptoms reviewed, drops stopped. | 99212/99213 with POS 10 and modifier -95 | No examination elements can be performed remotely, so eye codes are out. Straightforward-to-low MDM supports 99212–99213; check the payer's current telehealth policy. |
Notice the pattern. Scenarios 1, 2, 5, 6 and 10 are evaluations of the visual system: eye codes. Scenarios 4, 7, 11 and 12 are medical management: E/M. Scenarios 8 and 9 are procedures. Only scenario 3 is a genuine coin flip, and it is the lowest-value visit on the list. Most of the money in a practice rides on getting scenarios 1, 6 and 11 right, which is exactly where the "it's about the eyes, so it must be 92014" reflex costs practices the most: a documented 99214 often pays more than a 92012 that got billed because the comprehensive elements were not all there.
When 92004 vs 92002 vs 92012 (the new-vs-established and comprehensive-vs-intermediate decision)
The four core eye codes split on two axes. A patient is new if no provider of your specialty in your group has seen them face-to-face in the prior three years, and established otherwise. An exam is comprehensive if every comprehensive ophthalmological element is documented and a diagnostic and treatment program is started or continued, and intermediate otherwise. New + intermediate is 92002; new + comprehensive is 92004; established + intermediate is 92012; established + comprehensive is 92014.
| Code | Patient status | Exam level | 2026 Medicare avg (approx.) |
|---|---|---|---|
| 92002 | New | Intermediate | $70–$95 |
| 92004 | New | Comprehensive | $120–$165 |
| 92012 | Established | Intermediate | $60–$85 |
| 92014 | Established | Comprehensive | $95–$135 |
The 4-question decision tree
Run any visit through these four questions in order; the answers determine the code.
- Has the patient been seen face-to-face by any provider of your specialty in your practice in the prior 3 years?
- No → New patient (92002 or 92004 candidate)
- Yes → Established patient (92012 or 92014 candidate)
- Does the documentation contain all comprehensive ophthalmological service elements (history, general medical observation, external exam, internal exam, gross visual fields, basic sensorimotor) plus initiation or continuation of a diagnostic and treatment program?
- Yes → Comprehensive (92004 or 92014)
- No → Intermediate (92002 or 92012)
- Is the visit really driven by medical decision-making rather than by examination? If the problems, data and risk are the substance of the visit, level it as an E/M (99202–99215) instead. Do not report both an eye code and an E/M for the same evaluation.
- Is there medical necessity supported by the diagnosis code? If the visit is routine vision only, bill the vision plan. Medicare and most medical plans deny an eye code or E/M without a medical complaint or diagnosis.
What's the difference between 92004 and 92002?
Both are new-patient eye codes. 92004 is comprehensive: all comprehensive ophthalmological elements plus initiation of a diagnostic and treatment program. 92002 is intermediate: evaluation of a new or existing condition complicated by a new problem, with history, external exam and other procedures as indicated, but without the full comprehensive set. The comprehensive service pays roughly $40–$80 more, which is why documenting the fields and sensorimotor exam you actually performed matters.
Documentation requirements per code
| Element | 92002 / 92012 (intermediate) | 92004 / 92014 (comprehensive) |
|---|---|---|
| History and chief complaint | Required | Required |
| General medical observation | Required | Required |
| External eye and adnexa exam | Required | Required |
| Internal exam (ophthalmoscopy) | As indicated | Required (dilated, or reason not to dilate documented) |
| Visual acuity | Required | Required |
| Gross visual fields | Optional | Required |
| Basic sensorimotor exam | Optional | Required |
| Initiation / continuation of diagnostic and treatment program | If applicable | Required |
The three-year clock resets to "new" after the last face-to-face service, so a patient last seen four years ago is billed 92002 or 92004 again. The full descriptor set is in the optometry CPT codes guide, and the new-patient E/M ladder is covered in 99202 vs 99203 vs 99204 for optometry.
Does Medicare pay for CPT 92250?
Yes. Medicare pays for fundus photography (CPT 92250) when it is medically necessary to diagnose or manage a covered condition such as diabetic retinopathy, glaucoma, macular degeneration or a choroidal nevus, and the interpretation and report are in the chart. It does not pay for 92250 as a screening or "baseline" photo without a qualifying diagnosis, and most MACs will not pay 92250 and OCT (92133 or 92134) on the same date unless the necessity for both is documented. 92250 is bilateral, so report it once without -RT/-LT. Frequency, pairing rules and the OCT codes are covered in 92250 vs 92133 vs 92134.
Denial-proof documentation checklist
A comprehensive eye code survives review when every required element is visibly documented and the plan is explicit; an E/M code survives review when the MDM elements (or total time) are stated in the note rather than implied. Copy the list below into your exam template as a sign-off gate.
For 92004 / 92014
- ☐ Chief complaint in the patient's words, and the medical diagnosis that supports the claim
- ☐ New vs established status confirmed against the 3-year rule
- ☐ History: ocular, medical, medications, allergies, family history
- ☐ General medical observation (a sentence is enough)
- ☐ Visual acuity, each eye, with correction noted
- ☐ External exam: lids, lashes, conjunctiva, cornea, anterior chamber, iris, lens
- ☐ Internal exam: dilated fundus (disc, C/D, macula, vessels, periphery) or the documented reason not to dilate
- ☐ Gross visual fields (confrontation) recorded
- ☐ Basic sensorimotor: motility, cover test, pupils
- ☐ Tonometry with method and time
- ☐ Assessment and plan that starts or continues a diagnostic or treatment program (order, prescription, referral, recall interval with reason)
- ☐ Refraction on its own line as 92015 with the right modifier for the payer
For 99213 / 99214
- ☐ Problems addressed, each named with status (new, stable, worsening)
- ☐ Data: each test ordered, each test independently interpreted (write the interpretation), each external record reviewed
- ☐ Risk: prescription drug management, decision about minor or major procedure, social determinants that affect management
- ☐ If levelling by time: total minutes on the date of service and what the time was spent on
- ☐ Modifier -25 only when the E/M is significant and separately identifiable from a same-day procedure
- ☐ Medical diagnosis first; Z01.00/Z01.01 routine exam codes never lead an E/M claim
Modifier rules for eye-care claims (-25, -RT/-LT, -GA, -GY, -55, -95) are in the optometry billing modifiers guide.
Common denials for 92014 and 99214 and how to fix them
Most eye-code and E/M denials trace back to five reason codes, and each has a mechanical fix at the claim or documentation level rather than an appeal.
| Denial code | What it means on an eye-care claim | Fix |
|---|---|---|
| PR-49 — routine exam not covered | The claim went to medical insurance with a routine diagnosis (Z01.00, H52.x alone) leading, or the payer read the visit as a vision exam. | Lead with the medical diagnosis that drove the visit. If there is none, the visit belongs on the vision plan, not the medical claim. |
| CO-97 — bundled / included in another service | An exam code was billed inside a surgical global period, or an E/M was billed with a same-day procedure without -25. | Inside a global: bill the surgical code with -55 for co-management. With a procedure: append -25 to the E/M only if the note supports a separate service. |
| CO-4 — modifier inconsistent or missing | Bilateral 92250 with -RT/-LT, 92015 to Medicare without -GY, or -25 on an eye code. | Report bilateral tests once with no laterality modifier; -GY on Medicare refraction; -25 belongs on E/M codes, not 920xx. |
| CO-16 — claim lacks information | Missing referring provider on a diabetic exam, missing place of service, or a diagnosis pointer that does not connect to the line. | Populate the referring NPI, POS 11 (or 10 for telehealth from home), and point each CPT line to the diagnosis that justifies it. |
| Frequency / medical necessity (varies by payer, often CO-151 or CO-50) | A second 92014 within 12 months with no new problem, or a 99214 whose note reads as low MDM. | Document the new problem that required a comprehensive service, or level the follow-up honestly as 92012 / 99213. Do not upcode to the annual pattern. |
Practices that catch these before submission, rather than in the ERA, are the ones that scrub the claim against the note. That is the job of optometry billing and coding software that can see the exam, and it is why the code should be chosen while the findings are still on the screen instead of reconstructed at the end of the day.
Jelo drafts the ICD-10 and suggests the code while you finish the exam
Jelo's AI scribe for optometry is built into the exam. It is currently in development as an add-on from $70 per month on top of the $300 per month Jelo platform; book a demo for early access. As acuities, refraction, slit-lamp, tonometry and fundus findings are entered, it drafts the assessment and plan, proposes the ICD-10 codes, and suggests whether the documented elements support 92014, 92012 or an E/M level such as 99214, with a citation to the finding behind each suggestion. There is no microphone and no separate app; the doctor accepts, edits or rejects each line, and nothing saves to the chart or the claim until the OD signs. The approved codes flow into Jelo's built-in billing, so the note, the claim and the optical order never disagree.
If you want to see it run on one of the twelve scenarios above, book a 20-minute demo or read how the exam-native scribe compares with general-medicine dictation tools. For the authoritative descriptors and current fee schedule, keep the AOA coding and reimbursement guidance bookmarked and check the CMS fee schedule every January.