CPT 92004Comprehensive Eye Exam, New Patient
Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; comprehensive, new patient, 1 or more visits
CPT 92004 reports a comprehensive eye examination for a new patient. It covers a full medical evaluation including history, general medical observation, external and internal examination, visual acuity, refraction, tonometry, gross visual fields, binocular vision, and basic sensorimotor examination. The exam must include initiation of a diagnostic and treatment program.
When to use CPT 92004
Use CPT 92004 for a new patient (not seen by any provider in your practice within the last 3 years) receiving a comprehensive eye exam with initiation of diagnostic and treatment program. Requires all elements of a comprehensive ophthalmological service.
Documentation requirements
- New patient (no face-to-face service from any provider of same specialty in your practice within 3 years)
- Chief complaint and history of present illness
- Past ocular, medical, and family history
- Visual acuity (distance and near)
- External examination of the eye and adnexa
- Internal examination including ophthalmoscopy
- Gross visual fields
- Basic sensorimotor examination
- Biomicroscopy (slit-lamp) where indicated
- Tonometry where indicated
- Initiation of a diagnostic and treatment program
Reimbursement
$120 to $165 (varies by locality and payer)
National averages only. Rates vary by locality, payer, and fee schedule. Verify with your contracted payers.
Common modifiers
- -25 (significant E/M same day)
- -57 (decision for surgery)
- -GA (waiver on file)
- -GY (statutorily excluded)
Common denial reasons for CPT 92004
- Patient seen within last 3 years (should bill 92014 instead)
- Documentation missing required comprehensive elements
- Diagnosis code not medically necessary for the service
- Routine vision exam billed to medical plan without a medical complaint
- Missing initiation of diagnostic and treatment program
Jelo's exam-native AI scribe reads the findings you chart and drafts the ICD-10 codes, the assessment and the plan, then suggests whether the visit supports CPT 92004 or an E/M level. You review and sign; nothing files without you.
Stop losing revenue to coding errors
Jelo's integrated EHR and billing flags denial risks before you submit. Built-in CPT and ICD-10 suggestions match your exam documentation to the right code the first time. See how independent ODs cut denials by 40% with Jelo's optometry EHR software.
Worked example: billing CPT 92004
A 54-year-old new patient presents with blurred near vision. The visit includes history, visual acuity, refraction, slit-lamp exam, tonometry (IOP 16/17 mmHg) and a dilated fundus exam. Findings: presbyopia and early nuclear cataracts in both eyes. Plan: spectacle prescription, cataract education, 12-month recall. Bill 92004 with H52.4 and H25.13, plus 92015 on a separate line for the refraction. The patient has not been seen by any provider in the practice within 3 years, so 92004 applies rather than 92014.
ICD-10 codes commonly paired with CPT 92004
Validated against the FY2026 ICD-10-CM set. Pick the most specific diagnosis the chart supports; payers deny exam codes billed with a diagnosis that does not establish medical necessity.
| ICD-10-CM | Description |
|---|---|
| Z01.00 | Encounter for examination of eyes and vision without abnormal findings |
| Z01.01 | Encounter for examination of eyes and vision with abnormal findings |
| H52.13 | Myopia, bilateral |
| H52.4 | Presbyopia |
| H25.13 | Age-related nuclear cataract, bilateral |
| H40.013 | Open angle with borderline findings, low risk, bilateral |