Code description of CPT code 92012 and 92014

Medical coders still have lot of confusion in using Ophthalmological services for new and established patients. If you know the exact reason for which this exams are performed you would easily learn about these codes. I will just share about the established patient in this post and when should they be used. Let use check CPT code 92012 and 92014 codes description first.

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

The physician sees an established patient for intermediate ophthalmological services. The patient’s medical history is reviewed. General medical observations, an external ocular and adnexal examination, and other diagnostic procedures like ophthalmoscopy, biomicroscopy, or tonometry are done when required to continue the diagnostic and treatment regimen. The visit may include mydriasis (the dilation of the patient’s pupils).

Generally, the patient has an acute condition that does not require a comprehensive service or the patient is being examined for a chronic, but stable, condition (i.e., known cataract). CPT code 92012 is reported when the service is intermediate for established patient.

“Intermediate ophthalmological services describes 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.”

Read also: Eye related ICD 10 coding guide

92014 Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive, established patient, 1 or more visits

The physician sees an established patient, one who has been seen by a doctor in that group practice within the last three years, for comprehensive ophthalmological services. The physician performs a complete visual system examination, reviews the patient’s medical history, and performs a general medical observation in addition to external and ophthalmoscopic examinations. Gross visual fields and basic sensorimotor examinations are also done, including biomicroscopy, examination with cycloplegia (temporary immobilization of the ciliary body) or mydriasis (the dilation of pupils), and tonometry.

Other examination techniques such as retinoscopy, keratometry, slit lamp viewing, tear testing, corneal staining, corneal sensitivity, fundus examination, and exophthalmometry may also be employed and are included in the comprehensive exam when initiation or continuation of diagnostic or treatment programs is dependent upon the examining techniques. It may take more than one patient encounter to complete the service. CPT code 92014 is reported when the service is comprehensive, established patient.

CPT guidelines do not define the elements of “complete” visual system examination, but do describe what constitutes “comprehensive ophthalmological services.” Codes 92004, Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; comprehensive, new patient, 1 or more visits, and CPT code 92014, Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive, established patient, 1 or more visits, describe comprehensive ophthalmological services that include a general evaluation of the complete visual system.

The comprehensive services constitute a single service entity, which does not have to be performed at one session. The service 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. Intermediate and comprehensive ophthalmological services constitute integrated services in which medical decision making cannot be separated from the examining techniques used.

Itemization of service components, such as slit lamp examination, keratometry, routine ophthalmoscopy, retinoscopy, tonometry, or motor evaluation, is not applicable. For example, comprehensive services required for the diagnosis and treatment of a patient with symptoms that indicate a possible disease of the visual system, such as glaucoma, cataract or retinal disease, or to rule out disease of the visual system in a new or established patient.

Numerous CPT ophthalmology codes do not include the unilateral or bilateral designation in the descriptor, which often causes confusion when reporting these services. In these situations, modifier 50 may be appended, but modifier 52 is not needed to indicate that the procedure was performed on only one eye. From a CPT coding perspective, the following examples are procedures in which modifier 50 may be appended.

CPT coding guidelines may, however, differ from third-party payer guidelines, eligibility for payment, and coverage policy, as determined by each individual insurer or third-party payer. For example, for Medicare reporting purposes, each of the following codes have “bilateral indicator” (0, 1, 2, 3) assignments to indicate bilateral modifier usage and to determine appropriate reimbursement, as more fully discussed below.