By Stephanie Adams Ophthalmology Coding
CPT Code 92002 vs 92004: What’s the Key Difference?
CPT 92002 covers intermediate ophthalmoscopic examination for new patients with problem-focused evaluation, including visual acuity testing and targeted ophthalmoscopy for specific complaints.
CPT 92004 represents comprehensive ophthalmoscopic examination for new patients, including complete visual system assessment, detailed refraction, full external/internal eye examination, and binocular function evaluation.
Key takeaway: Use 92002 for focused visits addressing specific symptoms; use 92004 for complete baseline eye health assessments.
How Often Can You Bill OCT of Retina (92134)?
Billing frequency depends on medical necessity and patient condition:
- Stable conditions: Annually or as clinically indicated
- Active retinal diseases: Monthly monitoring may be justified for diabetic macular edema, wet AMD, or other progressive conditions
- Insurance requirements: Most payers require documented medical necessity and adherence to clinical guidelines
Documentation tip: Always justify frequency based on disease activity and established treatment protocols.
A-Scan Ultrasound (76519) vs IOL Master (92136): Which to Choose?
A-Scan Ultrasound (76519):
- Contact-based measurement using sound waves
- Less patient comfort
- Lower accuracy with dense cataracts
IOL Master (92136):
- Non-contact optical coherence interferometry
- Superior accuracy and repeatability
- Provides additional measurements (white-to-white distance, anterior chamber depth)
- Gold standard for modern cataract surgery planning
Can You Bill Both CPT 66984 and 66982 for the Same Patient?
Same eye, same session: No – these codes are mutually exclusive for the same surgical procedure.
Different eyes: Yes – if surgical complexity differs between eyes (e.g., routine surgery on one eye, complex surgery on the other).
Code selection: Base decision on actual surgical complexity encountered and document thoroughly in operative reports.
Annual Limits for Intravitreal Injections (67028)
No specific annual limits exist, but frequency varies by condition:
- Initial treatment: May require monthly injections (up to 12+ per year)
- Maintenance phase: Every 4-12 weeks depending on patient response
- Coverage factors: Insurance follows FDA-approved dosing and clinical guidelines
Best practice: Document treatment response and adjust intervals based on disease activity.
Documentation Requirements for Complex Cataract Surgery (66982)
Pre-operative documentation must include:
- Dense/mature cataracts
- Small pupils requiring expansion
- Weak zonules
- Pseudoexfoliation syndrome
- Previous trauma history
Operative report requirements:
- Specific complexity factors encountered
- Additional techniques used
- Specialized equipment required
- Extended surgical time
Post-operative notes: Document complications or additional maneuvers supporting complexity designation.
Prior Authorization for Glaucoma Surgeries
Common requirements vary by payer but typically include:
- Failed medical therapy documentation
- Trial of multiple glaucoma medications
- Evidence of disease progression
- IOP measurements despite treatment
- Visual field defects and optic nerve changes
Affected procedures:
- Trabeculectomy (66170)
- Transluminal dilation (66174)
- Aqueous drainage devices (66183)
Timeline: Submit authorization requests well before planned procedures.
Same-Day Billing: Fundus Photography (92250) + OCT
Generally allowed – these procedures provide complementary diagnostic information:
- Fundus photography: Broad retinal overview and permanent record
- OCT: Detailed cross-sectional retinal analysis
Insurance considerations: Verify payer-specific policies for same-day diagnostic procedures and ensure medical necessity documentation for both.
Laser Trabeculoplasty (65855) vs Surgical Glaucoma Procedures
Laser Trabeculoplasty (65855):
- Minimally invasive office procedure
- 10-15 minutes duration
- Can be repeated
- Uses existing drainage pathways
Surgical Procedures (66170, 66174, 66183):
- More invasive interventions
- Create new drainage pathways or implant devices
- Reserved for failed medical/laser therapy
- Longer recovery, higher complication risk
Global Period for Cataract Surgery
Standard global period: 90 days for cataract surgery codes (66984, 66982, 66987)
Included services:
- Routine post-operative visits
- Wound care
- Expected post-operative management
Separately billable during global period:
- Complications requiring significant additional services
- Unrelated conditions (with appropriate modifiers)
Age Restrictions for Ophthalmology CPT Codes
General rule: No specific age restrictions for most ophthalmology codes
Key factors:
- Medical necessity drives billing appropriateness
- Some procedures more common in certain age groups
- Insurance policies may vary by age for specific interventions
- Pediatric considerations may apply for cooperation-dependent procedures
Bilateral Same-Day Cataract Surgery
Standard practice: Not recommended due to bilateral complication risk (especially endophthalmitis)
Typical approach: Sequential surgery with days to weeks between procedures
Exceptional circumstances:
- Requires clear medical justification
- Appropriate CPT modifiers necessary
- Prior authorization may be required
- Comprehensive documentation of medical necessity
Risk consideration: Document rationale for deviating from standard practice guidelines.
Eye Care Billing Consultants (ECBC) Can Help with Ophthalmology CPT Codes.
If you are struggling to fully understand ophthalmology CPT codes on your own, and would like someone to lessen the load, then reach out to ECBC today. Our complete ophthalmology billing services will ensure your billing is optimized, which will allow you to focus on who matters most, your patients.
