Ophthalmology and Optometry Coding Alert

Consult this guide before picking a code for your next office visit. 

E/M Codes:

New patient: Has not seen the physician, or another physician of the same specialty in the same group practice, within the past three years.

• 99201: Must include problem-focused history, problem-focused exam, and straightforward medical decision making

• 99202: Must include expanded problem-focused history, expanded problem-focused exam, and straightforward medical decision making

• 99203: Must include detailed history, detailed exam, and low-complexity medical decision making

• 99204: Must include comprehensive history, comprehensive exam, and moderate-complexity medical decision making

• 99205: Must include comprehensive history, comprehensive exam, and high-complexity medical decision making

Established patient: Has seen the physician, or another physician of the same specialty in the same group, within the past three years.

• 99211: May not require the presence of a physician

• 99212: Must have two of three: problem-focused history, problem-focused exam, or straightforward medical decision making

• 99213: Must have two of three: expanded history, expanded exam, or low-complexity medical decision making

• 99214: Must have two of three: detailed history, detailed exam, or moderate-complexity medical decision making

• 99215: Must have two of three: comprehensive history, comprehensive exam, or high-complexity medical decision making

Note: To help differentiate between different levels of service, see the “Instructions for Selecting a Level of E/M Service” section in the introduction to the E/M codes in the CPT^® handbook.

General Ophthalmological Services Codes

New patient: Has not seen the physician, or another physician of the same specialty in the same group practice, within the past three years.

• 92002 — Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; intermediate, new patient

• 92004 — … comprehensive, new patient, 1 or more visits.

Established patient: Has seen the physician, or another physician of the same specialty in the same group, within the past three years

• 92012 — Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established patient

• 92014 — … comprehensive, established patient, 1 or more visits.

Intermediate Vs. Comprehensive:

Intermediate ophthalmological service (92002 or 92012): An evaluation of a new or existing condition complicated with a new diagnostic or management problem not necessarily relating to the primary diagnosis.

Comprehensive ophthalmological service (92004 or 92014): A general evaluation of the complete visual system. It always includes initiation of diagnostic and treatment programs.

Note: Check with your carrier for additional rules pertaining to intermediate and comprehensive services. Also check with your state to determine if guidelines exist for ophthalmic/optometric exams.