- Comprehensive
- 92004- new comprehensive eye visit
- Definition: Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; comprehensive, new patient, one or more visits.
- 92014- return comprehensive eye visit
- Definition: Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive, established patient, one or more visits.
- Requires initiate or continuing a diagnostic and/or treatment plan
- Requires all 12 elements of the eye exam (see checklist below)
- Dilation as medically necessary. If not dilated, document reason.
- Intermediate
- 92002- new intermediate eye visit
- 92012- return intermediate eye visit
- Must perform at least 3 eye exam elements
| Section | Required Element |
|---|---|
| History | Chief Complaint |
| History of Illness | |
| General Medical Observation | |
| Examination | Visual Acuity |
| Visual Fields (gross or confrontation) | |
| Extraocular motility | |
| Intraocular Pressure | |
| Ocular Adnexa | |
| Conjunctiva | |
| Cornea | |
| Anterior Chamber | |
| Pupil and Iris | |
| Lens | |
| Optic Nerve | |
| Retina and vessels | |
| Initiation of Diagnostic and Treatment Program (use one of many possible actions) | Prescription of medication, glasses, contact lenses |
| Arranging for diagnostic or treatment services | |
| Order Consultation | |
| Order Labs | |
| Order Radiology testing | |
| Schedule or perform surgery | |
| Scheduling necessary follow-up |
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