On this page
Key takeaways
- 92004 is the complete eye exam code for new patients, and 92014 is the code for established patients.
- A new patient has not been seen by the same specialty in the same group in the past 3 years.
- The exam must evaluate the complete visual system and start a diagnostic and treatment plan.
- 92004 cannot be billed with 99204 or another E/M visit code for the same visit.
What Is CPT Code 92004?
CPT 92004 is the code for a full ophthalmological exam of a new patient, which evaluates the complete visual system and starts a diagnostic and treatment plan. It can be completed in 1 or more visits and is billed once.
92004 sits in the eye exam code family with 92002, 92012 and 92014, listed in the ophthalmology CPT codes guide. Ophthalmologists and optometrists both use it.
Who Counts as a New Patient for 92004?
A new patient is one who has not received any professional face-to-face service from a provider of the same specialty in the same group in the past 3 years. A patient seen 4 years ago is new again.
These cases cause the most new patient errors in eye practices.
- A patient seen by an optometrist in the group and then by an ophthalmologist, which is new for the ophthalmologist because the specialties differ
- A patient seen by another ophthalmologist in the same group, which is established
- A patient seen only for a technician test in the past 3 years, which is usually still new because no professional service was given
Some commercial payers apply their own group rules, so check the payer policy when the history is unclear.
What Must a 92004 Exam Include?
A 92004 exam must evaluate the complete visual system, including history, general medical observation, external and ophthalmoscopic exams, gross visual fields and a basic sensorimotor exam. CPT adds that it often includes biomicroscopy, a dilated exam and tonometry.
The record should show each element and the plan that comes from it.
- History. Chief complaint, eye and medical history and medications.
- Exam. External exam, slit lamp, pressure, motility, fields and dilated fundus exam.
- Assessment. A diagnosis or finding for each problem.
- Plan. Tests, treatment or follow-up that starts the care program.
When dilation is not done, write why, such as a narrow angle or the patient's refusal.
How Is 92004 Different From 92002 and 99204?
92004 is a complete new patient exam, 92002 is an intermediate new patient exam and 99204 is a new patient E/M visit leveled by medical decision making or time. All 3 are valid for a new patient, and the record decides which one fits.
| Factor | 92002 | 92004 | 99204 |
|---|---|---|---|
| Code family | Eye exam | Eye exam | E/M |
| Scope | Focused on a new or existing condition | Complete visual system | Any medical problem |
| How it is leveled | Exam elements | Exam elements and a treatment plan | Moderate decision making or time |
| Typical use | A red eye or a single new complaint | A full first exam | A complex medical visit |
Only one visit code is billed for a visit. A complex new medical problem with moderate decision making may fit 99204 better, while a full exam with a simple plan usually fits 92004.
Which Services Are Billed Separately From 92004?
Refraction, diagnostic tests and procedures are billed separately from 92004, each with its own code and documentation. The exam code covers the evaluation only.
| Service on the same day | Code | Billed to |
|---|---|---|
| Refraction | 92015 | The patient or a vision plan, since Medicare excludes it |
| OCT of the optic nerve or retina | 92133 or 92134 | Medical insurance, with a covered diagnosis |
| Fundus photography | 92250 | Medical insurance, with a covered diagnosis |
| Visual field | 92083 | Medical insurance, with a covered diagnosis |
| Minor procedure, such as punctal plugs | 68761 | Medical insurance, with modifier 25 on the exam |
The exam carries modifier 25 only when a minor procedure is done on the same day.
How Do Medicare and Vision Plans Treat 92004?
Medicare pays 92004 for a medical eye exam and does not pay for a routine exam, while vision plans pay for routine exams under their own rules. The reason for the visit decides who is billed.
A new patient who comes in for blurred vision from a cataract has a medical visit, billed to Medicare with the cataract diagnosis. A new patient who wants new glasses has a routine visit, billed to the vision plan with Z01.00 or Z01.01. The 2026 Medicare national office amount for 92004 is roughly $150 before geographic adjustment. Our vision plan billing team routes each visit to the right payer.
What Does a 92004 Claim Look Like?
A 92004 claim bills the exam once, with the diagnosis that caused the visit, and lists refraction on its own line. The example shows a new Medicare patient seen for blurred vision.
| Claim line | Diagnosis | Payer |
|---|---|---|
| 92004 | H25.13, age-related nuclear cataract, both eyes | Medicare |
| 92015-GY | H52.4, presbyopia | Patient, as a non-covered service |
Modifier GY tells Medicare that refraction is excluded by law, so the patient can be billed for it.
Why Do 92004 Claims Deny?
92004 claims deny most often because the patient is established, the exam is not complete or the visit is routine. These checks prevent most of them.
- A patient seen by the same specialty in the group within 3 years
- Missing exam elements, such as no fundus exam or no pressure check
- A routine diagnosis sent to Medicare
- 92004 and an E/M code billed for the same visit
Our ophthalmology medical coding services check new patient status and exam elements on every visit before the claim is sent.