CPT Code: 92004  Region: 37

States covered:  General guidelines if your state does not have a local coverage determination

Title:  Comprehensive Ophthalmological Examination - New Patient

Category
General Ophthalmological Services

Description
Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; comprehensive, new patient, one or more visits

This Medicare carrier does not have a local coverage determination (LCD) for a comprehensive ophthalmologic examination.  The policy presented is a sample and it is provided as a reference guide only and should not be construed as policy for your current Medicare carrier.  



There are two levels of General Ophthalmological Service – Intermediate and Comprehensive.

According to the Current Procedural Terminology Codebook, “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, retinoscopy, tonometry, or motor evaluation is not applicable.”

The comprehensive level of service describes an evaluation of the complete visual system.

Remember, the intensity of a service is a function of medical necessity.  The intensity of an eye examination is defined by the number and type of service components that are performed.  The decisions regarding examination intensity are based upon the following:

  • The clinical judgement of the optometrist or ophthalmologist
  • Patient’s medical and ocular history
  • The nature of the presenting problem or problems

1.  Identification and/or follow-up for Disorders of the Eye and Adnexa

  • Disorders of the globe
  • Retinal detachments and defects
  • Other retinal disorders
  • Chorioretinal inflammations, scars, and other disorders of the choroids
  • Disorders of the iris and ciliary body
  • Glaucoma
  • Cataract
  • Visual disturbances
  • Blindness and low vision
  • Keratitis
  • Corneal opacity and other disorders of the cornea
  • Disorders of the conjunctiva
  • Inflammation of the eyelids
  • Other disorders of the eyelids
  • Disorders of the lacrimal system
  • Disorders of the orbit
  • Disorders of the optic nerve and visual pathways
  • Strabismus and other disorders of binocular eye movements
  • Other disorders of the eye

2.  Identification and/or follow-up for Infectious and Parasitic Diseases

3.  Identification and/or follow-up for Neoplasms

4.  Identification and/or follow-up for Endocrine and Nutritional Diseases                

5.  Identification and/or follow-up for Mental Disorders

6.  Identification and/or follow-up for Diseases of the Nervous System and Sense Organs

7.  Identification and/or follow-up for Diseases of the Circulatory System

8.  Identification and/or follow-up for Diseases of the Skin and Subcutaneous Tissue

9.  Identification and/or follow-up for Diseases of Connective Tissue

10.  Identification and/or follow-up for Congenital Anomalies of the Eye

11.  Identification and/or follow-up for Symptoms, Signs, and Ill-Defined Conditions

12.  Identification and/or follow-up for Ocular Injury and Poisoning

13.  Identification and/or follow-up for Complications of Surgical and Medical Care

14.  Identification and/or follow-up for Conditions Influencing Health Status

  • Problems with special senses and other functions
  • Organ or tissue replaced by transplant or other means
  • States following surgery of the eye and adnexa
  • Long-term use of medications

1.  Documentation supporting the medical necessity of an eye examination should be legible, maintained in the patient’s medical record, and must be made available to Medicare upon request.  

2.  This Medicare carrier follows Current Procedural Terminology’s (CPT) documentation requirements for comprehensive level services.


GENERAL CPT GUIDELINES
 

Current Procedural Terminology describes medical eye examinations as General Ophthalmological Services. 

Two levels of intensity can be provided – intermediate and comprehensive. 

The medical eye examination is divided into nine (9) service components: 

  • Patient History
  • General Medical Observation
  • Gross Visual Fields
  • Basic Sensorimotor Examination
  • External Examination
  • Adnexal Examination
  • External Ocular Examination
  • Ophthalmoscopic Examination
  • Initiation or Continuation of Diagnostic & Treatment Program 

In addition to these service components, the examination often includes several routine optometric examination techniques such as keratometry, retinoscopy, tonometry, laser interferometry, exophthalmometry, or Shirmer’s tear testing and may include a fundus examination with the pupils dilated – unless pupillary dilation is medically contraindicated.  By definition, these various examination techniques are integrated within the diagnostic evaluation. They should not be coded as separate services. 

1.  For a comprehensive ophthalmologic examination, this Medicare carrier’s documentation requirements follow Current Procedural Terminology’s documentation guidelines.  The following seven (7) service components must be included in the examination to meet the documentation requirements for a comprehensive ophthalmological examination: 

  • Patient History
  • General Medical Observation
  • Gross Visual Fields
  • Basic Sensorimotor Examination
  • External Examination
  • Ophthalmoscopic Examination
  • Initiation or Continuation of Diagnostic & Treatment Program 

Comprehensive ophthalmological examination would be appropriate for a new or established patient if the patient has symptoms indicating a possible disease of the visual system and there is a diagnosis and treatment of the condition, such as retinal disease, cataracts, glaucoma, or to rule out a disease of the visual system. 

Initiation of a Diagnosis & Treatment Program can include prescribing medications, lenses, other therapies, arranging further diagnostic test, procedures or treatment services, consultations with specialist, or arranging laboratory and radiological services.  It also includes a discussion of diagnostic and treatment options, the condition’s severity, the prognosis, any continuation of diagnostic and treatment plans, any continuation or changes in medications and appropriate follow up visits. 

1.  Report an comprehensive eye examination for a new patient with CPT code 92004. 

2.  All of the coverage criteria must be met before Medicare can reimburse this service. 

3.  The diagnosis code(s) must be representative of the patient’s condition. 

4.  Services that require less detailed ophthalmologic examination techniques than the General Ophthalmological Services are reported by using the Evaluation and Management Codes. 

5.  Vision screenings at nursing homes or to a general population is not covered. 

6.  Refraction is a non-covered service and is not included in a medical eye examination.  If the purpose of the office visit is for correction of refractive errors, the General Ophthalmological Service itself is also not covered. When billing for denial purposes, refractive services are reported separately as CPT code 92015.

There are no specific utilization guidelines for General Ophthalmological Services.  In the absence of specific utilization guidelines, optometrists should adhere to CMS Ruling 95-1 (V) which states that utilization of these services should be consistent with locally acceptable standards of ophthalmic practice.

Services that exceed the accepted standards of optometric/ophthalmologic practice may be deemed not medically necessary.

Some retired local coverage determinations denied more than two comprehensive level examinations in any twelve month period as not medically necessary.