Eye code visits are either comprehensive or intermediate for both new and established patients. Keep in mind the definition of a new patient is one who hasn't received any professional services from the physician or another physician of the same specialty in the same group practice within the past three years. Below are the (most common) 920XX codes:
92002 (Ophthalmological services): Medical examination and evaluation with initiation of diagnostic treatment program; intermediate, new patient.
92004 (Ophthalmological services): Medical examination and evaluation with initiation of diagnostic treatment program; comprehensive, new patient, one or more visits.
92012 (Ophthalmological services): Medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established patient.
92014 (Ophthalmological services): Medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive, established patient, one or more visits.
The comprehensive exam
Comprehensive eye examination codes (92004, 92014) describe a general evaluation of the complete visual system. The CPT defines it as:
"Includes history, general medical observation, external and ophthalmoscopic examinations, gross visual fields and basic sensorimotor examination. It often includes, as indicated: biomicroscopy, examination with cycloplegia or mydriasis and tonometry. It always includes initiation of diagnostic and treatment programs."
Keep in mind that a comprehensive eye examination by definition requires gross visual fields and a basic sensorimotor examination, while other elements of an examination that most of us would expect to include aren't required. Notably, the CPT definition lists dilation as optional, although many carriers have policies stating that it's required unless medically contraindicated.
The intermediate exam
CPT defines intermediate codes (92002, 92012) as:
"An evaluation of a new or existing condition complicated with a new diagnostic or management problem not necessarily relating to the primary diagnosis, including history, general medical observation, external ocular and adnexal examination and other diagnostic procedures as indicated; may include the use of mydriasis for ophthalmoscopy."
As with comprehensive visits, dilation may be optional. Some clinicians use the intermediate codes to reduce the cost of an examination to a noninsured patient. This is inappropriate, as it's considered down coding a service that was provided. Many carriers have become aware of this billing pattern and have recaptured overpayments for their insured patients for similar services.