CPT Code 92004

CPT code 92004 is used for billing a comprehensive eye exam for new patients.

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What is CPT Code 92004

CPT code 92004 is designated for a comprehensive eye examination for a new patient. This includes a general evaluation of the complete visual system. The service typically involves a history review, general medical observation, external and ophthalmoscopic examination, gross visual fields, and basic sensorimotor examination. It may also include biomicroscopy, examination with cycloplegia or mydriasis, and tonometry as indicated.

Does CPT 92004 Need a Modifier?

For the CPT code 92004, which is used for a comprehensive eye examination for a new patient, several modifiers may be applicable depending on the specific circumstances of the service provided. Here’s an ordered list of potential modifiers and the reasons for their use:

1. -25 - Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service: This modifier is used if the physician performs a significant, separate service in addition to the eye exam on the same day.

2. -57 - Decision for Surgery: Apply this modifier if the eye exam leads to the decision to perform surgery.

3. -LT and -RT - Left side and Right side: These modifiers are used to specify services performed on one side of the body. Although less common for a comprehensive exam, they might be applicable if only one eye was examined due to specific circumstances.

4. -24 - Unrelated Evaluation and Management Service by the Same Physician During a Postoperative Period: If the eye exam is performed during the postoperative period of a different procedure and is unrelated to the original procedure, this modifier would be necessary.

5. -79 - Unrelated Procedure or Service by the Same Physician During the Postoperative Period: This is used if another distinct procedure is performed during the postoperative period of a different, unrelated surgery.

6. -22 - Increased Procedural Services: When the work required to perform the eye exam is substantially greater than typically required, this modifier can be used to indicate that the service was more complex than usual.

7. -52 - Reduced Services: If the eye exam is partially reduced or eliminated at the physician's discretion, this modifier indicates that the service was less extensive than usual.

Each of these modifiers addresses specific circumstances that might alter the billing or documentation requirements for the eye exam described by CPT code 92004. It's crucial for healthcare providers to accurately apply these modifiers to ensure proper reimbursement and compliance with billing regulations.

CPT Code 92004 Medicare Reimbursement

CPT code 92004, which refers to a comprehensive eye examination for a new patient, is generally reimbursed by Medicare. This code covers a complete and general evaluation of the complete visual system. The reimbursement for this code can vary based on geographic location and the specifics of the Medicare plan. For accurate and current reimbursement rates, it is advisable to consult the Medicare Physician Fee Schedule (MPFS) available on the CMS (Centers for Medicare & Medicaid Services) website or through Medicare administrative contractors that manage claims and payments in specific regions.

Are You Being Underpaid for 92004 CPT Code?

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