The “Eyes” Have it: Routine vs. Medical Eye Exams
Understanding the difference between routine and medical eye examinations will guide you to properly code these services and prevent your patient from receiving an unexpected bill. Coding eye examinations is different than coding physical examinations, which have separate CPT® codes for routine and medical visits.
CPT® codes 92002-92014 indicate new and established eye exams, and are used for both routine and medical visits. The primary diagnosis code makes the distinction.
• 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
• 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
A routine visit is indicated by a primary diagnosis code of V72.0 Special investigations and examinations; examination of eyes and vision, followed by any additional diagnostic findings. For example, if an eye exam is coded as 92002 with a primary diagnosis of V72.0, it is considered a routine exam; however, 92002 with a primary diagnosis of 379.91 Pain in or around eye would be considered a medical exam.
When a patient presents for an eye exam due to poor eyesight, he may believe this service to be covered by insurance. But insurers do not consider refractive errors (e.g., nearsightedness and farsightedness) to be medical diagnoses, and many do not cover routine vision exams. Consequently, there may be confusion on the patient’s part if his insurance company denies the service.
Clear up the confusion before the service is rendered by contacting the patient’s health insurance and determining if routine vision services are covered, the frequency of coverage, and if the patient has met or exceeded his limit of routine services. Ask the patient if he has separate vision coverage under another carrier. Ensure that your patient understands the difference in exams and what his insurance covers.
Nancy Clark, CPC, CPMA, CPC-I