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
Use the current payer fee schedule for this code, locality, service setting and date of service.
Rates and patient responsibility depend on the payer and service. No unsourced national average is presented here.
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
Verify CPT 92004 against official sources
Use the code set and payer policy applicable to the date of service. This educational reference is not a coverage decision or a substitute for a qualified coding review.
- CMS Physician Fee Schedule: select the year, locality and service setting before looking up payment information.
- CMS NCCI edits and manuals: check the applicable code-pair edits and modifier instructions.
- Medicare Coverage Database: find relevant coverage and documentation policies.
- AMA CPT resources: consult the current licensed code set.
A practical documentation check
- Match the documented service to the code definition.
- Confirm patient status, laterality, components and any required interpretation.
- Check coverage, edits and payer-specific requirements.
- Have the responsible clinician or billing reviewer resolve discrepancies before submission.
Editorial sources updated September 15, 2026. Published by Jelo.
Jelo’s AI scribe is an upcoming add-on from $70/month. It is being developed to assist with documentation and code suggestions; clinicians and billing staff must verify every code. It is not included in the live platform subscription.
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Review how the exam connects to the live billing workflow. Your team remains responsible for documentation, code selection and payer requirements. Explore 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
Verify suggested diagnoses against the current ICD-10-CM set and the documented encounter. A listed diagnosis does not by itself establish medical necessity or payer coverage.
| 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 |