Ophthalmology and Optometry Coding Alert

Question: When is it appropriate to use 92012 as opposed to 92014?

Virginia Subscriber

Answer: The main difference between 92012 (Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established patient) and 92014 (... comprehensive, established patient, one or more visits) is that 92014 requires dilation unless medically contraindicated.

A comprehensive exam (92014 for an established patient or 92004 for a new patient) also includes more exam components than an intermediate exam (92012 for an established patient or 92002 for a new patient). For example, an insurer may require that you include nine or more of these elements in a comprehensive exam:

• Visual acuity (not including refractive error)
• Gross visual fields
• Eyelids and adnexa
• Ocular mobility
• Pupils
• Iris
• Conjunctiva
• Cornea
• Anterior chamber
• Lens
• Intraocular pressure
• Retina (vitreous, macula, periphery, and vessels)
• Optic disc.

Tip: Some insurers may require that certain elements, such as gross visual field tests and ocular mobility tests, be covered in all comprehensive tests. Examination of the eyelids and adnexa may be mandatory for an intermediate exam. Most dilated exams will include nine or more of the above items.

Even though CPT® does not support this restriction, some insurers consider 92002-92014 to be used only for routine vision exams. Be sure to check your carrier for its rules. Some state statutes also have specific requirements for the elements that must be furnished and documented for a comprehensive examination.