Ophthalmology and Optometry Coding Alert

Question: What are the documentation requirements for the use of 92002-92014?

California Subscriber

Answer: HCFA does not have national criteria for documentation requirements for general ophthalmological services codes 92002 and 92004 for new patients and 92012 and 92014 for established patients. Many Medicare carriers, however, have published criteria in their bulletins or newsletters to providers or in local medical review policies (LMRPs.) These criteria must be followed for Medicare billing. Please note that many of these local Medicare policies require dilation unless contraindicated for a comprehensive examination (92004 and 92014).

For other payers and for Medicare carriers that have not published specific criteria, the 2001 CPT manual describes the definitions of intermediate ophthalmological services and comprehensive ophthalmological services, with examples, in the medicine section in the subsection of ophthalmology. The definitions state what the service includes. For instance, a comprehensive ophthalmological service includes a history, general medical observation, external and ophthalmoscopic examinations, gross visual fields and basic sensorimotor examination. It often includes, as indicated, biomicro-scopy, examination with cycloplegia or mydriasis and tonometry. It always includes initiation of diagnostic and treatment programs.