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Key takeaways
- 92012 is the intermediate eye exam code for established patients, used for most follow-up visits.
- An established patient has been seen by the same specialty in the same group within the past 3 years.
- 92012 covers a focused exam of a new or existing problem, while 92014 covers the complete visual system.
- Only one visit code is billed per visit, so 92012 is never billed with 92014 or an E/M code on the same visit.
What Is CPT Code 92012?
CPT 92012 is the code for an intermediate eye exam and evaluation of an established patient, used for a new or existing condition. The condition may come with a new diagnostic or management problem, even one unrelated to the main diagnosis.
92012 belongs to the eye exam family with 92002, 92004 and 92014 in the ophthalmology CPT codes list. It is the code eye practices bill most often for follow-up visits.
What Must a 92012 Exam Include?
A 92012 exam includes a history, general medical observation, an external eye and adnexa exam and the other tests the problem calls for. CPT notes it may include dilation.
The record should show these 4 parts.
- History. The reason for the visit and any change since the last one.
- Exam. The external and other exam elements the problem needs, such as pressure or a slit lamp exam.
- Assessment. The status of each problem, such as stable or worse.
- Plan. Treatment, tests or the next visit.
A focused exam is enough for 92012. The full visual system exam belongs to 92014.
How Is 92012 Different From 92014, 92002 and 99213?
92012 is the intermediate established patient exam, 92014 the complete established patient exam, 92002 the intermediate new patient exam and 99213 a low-level established E/M visit. The patient's status and the record decide which one fits.
| Code | Patient | Scope | Typical visit |
|---|---|---|---|
| 92012 | Established | Focused on one or more problems | Glaucoma pressure check, dry eye follow-up |
| 92014 | Established | Complete visual system | Yearly full exam with dilation |
| 92002 | New | Focused on one or more problems | A new patient with a red eye |
| 99213 | Established | Leveled by low decision making or time | A simple medical follow-up |
Practices compare the payment for 92012 and 99213 by payer and pick the code the record supports. Never bill both for one visit.
Which Visits Are Usually Billed With 92012?
Follow-up visits for a known eye condition and visits for a single new complaint are the visits most often billed with 92012. These are common examples.
- A glaucoma pressure check between full exams
- A dry eye or blepharitis follow-up
- A red eye, foreign body sensation or new floaters in an established patient
- A diabetic retinopathy follow-up between yearly exams
- An injection day visit with a separate problem, billed with modifier 25
The diagnosis should be the problem that brought the patient in that day.
Which Services Are Billed Separately From 92012?
Refraction, diagnostic tests and procedures are billed separately from 92012, each with its own code and documentation. The table lists the most common add-ons.
| Service on the same day | Code | Note |
|---|---|---|
| Refraction | 92015 | Medicare excludes it, so it is billed to the patient or a vision plan |
| Optic nerve OCT | 92133 | Needs a covered glaucoma or optic nerve diagnosis |
| Visual field | 92083 | Needs a covered diagnosis |
| Gonioscopy | 92020 | Common in glaucoma visits |
| Minor procedure | For example 68761 | The exam needs modifier 25 |
A visit inside a surgery's global period for routine post-op care is not billed. An unrelated visit in that period is billed 92012 with modifier 24.
What Does a 92012 Claim Look Like?
A 92012 claim bills the exam once with the diagnosis that caused the visit, and lists any test on its own line. The example shows a glaucoma follow-up with optic nerve OCT.
| Claim line | Diagnosis |
|---|---|
| 92012 | H40.1131, primary open-angle glaucoma, both eyes, mild stage |
| 92133 | H40.1131 |
The glaucoma code needs its eye and stage, as set out in the glaucoma ICD-10 codes guide.
Why Do 92012 Claims Deny?
92012 claims deny most often because the patient is new, the visit falls in a global period or a second visit code was billed. These checks prevent most of them.
- A patient not seen by the same specialty in the group within 3 years, who needs 92002 or 92004
- A routine post-op visit inside a global period
- 92012 billed with an E/M code or 92014 for the same visit
- A routine vision diagnosis sent to medical insurance
Our ophthalmology medical coding services check patient status, global periods and visit codes on every claim.