CPT Code 92004: Comprehensive 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
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