Ophthalmology CPT Codes Reference

Overview

This note is a comprehensive, vault-indexed reference for the most commonly used CPT codes in ophthalmology practice — covering evaluation and management, diagnostic imaging, in-office procedures, laser treatments, and surgical procedures. Key billing notes and NCCI considerations are included for each section.

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Evaluation and Management — Eye Exam Codes (92xxx)

These ophthalmology-specific exam codes are an alternative to standard E/M codes (99xxx) and are used when an ophthalmologist performs a structured eye examination as the primary service.

CPT	Description	Notes
92002	Ophthalmological services, new patient, intermediate	Focused examination; one or more elements of the examination
92004	Ophthalmological services, new patient, comprehensive	Complete examination including refraction
92012	Ophthalmological services, established patient, intermediate	Follow-up / focused visit
92014	Ophthalmological services, established patient, comprehensive	Complete exam including refraction

Key billing note: 92002-92014 are the codes most specific to ophthalmology examinations. Providers may alternatively use standard E/M codes (99202-99215) for office visits — payer policy and documentation type should guide the choice.

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General E/M Codes Used in Ophthalmology

CPT	Description
99202-99205	New patient, office/outpatient E/M, levels 2-5
99212-99215	Established patient, office/outpatient E/M, levels 2-5
99221-99223	Initial hospital inpatient E/M
99231-99233	Subsequent hospital inpatient E/M
99241-99245	Office consultation (some payers; not recognized by Medicare)
99251-99255	Inpatient consultation (some payers; not recognized by Medicare)

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Diagnostic Imaging and Testing

Ocular Coherence Tomography (OCT)

CPT	Description	Notes
92132	Scanning computerized ophthalmic diagnostic imaging, anterior segment, unilateral or bilateral	Anterior segment OCT — cornea, angle, AC assessment
92133	Scanning computerized ophthalmic diagnostic imaging, posterior segment, optic nerve	OCT optic nerve / RNFL — glaucoma monitoring
92134	Scanning computerized ophthalmic diagnostic imaging, posterior segment, retina	OCT retina — macula, CME, subretinal fluid, AMD monitoring

NCCI note: 92133 and 92134 can be billed together when both optic nerve and retina imaging are medically necessary and documented.
NCCI note: 92250 (fundus photography) and 92133/92134 are generally mutually exclusive per NCCI; use modifier XU or 59 when both are medically necessary.

Fundus Photography and Extended Ophthalmoscopy

CPT	Description	Notes
92250	Fundus photography with interpretation and report	Bilateral documentation of retinal pathology
92201	Extended ophthalmoscopy with retinal drawing, new patient	Included in same-day posterior segment surgery
92202	Extended ophthalmoscopy with retinal drawing, established patient	Included in same-day posterior segment surgery

Fluorescein and ICG Angiography

CPT	Description	Notes
92235	Fluorescein angiography with interpretation and report	Unilateral or bilateral; vasculitis, CME, AMD, DR
92240	Indocyanine green angiography with interpretation and report	Choroidal pathology, VKH, CSC
92242	Fluorescein and ICG angiography performed at the same session	Combo code when both are done together

Visual Field Testing

CPT	Description	Notes
92081	Visual field exam, limited	Monocular screening
92082	Visual field exam, intermediate
92083	Visual field exam, extended	Full threshold Humphrey / Goldmann; glaucoma, neuro-ophthalmology

Ultrasound

CPT	Description	Notes
76511	Ophthalmic ultrasound, diagnostic; A-scan only	Biometry
76512	Ophthalmic ultrasound; B-scan, with or without A-scan	Posterior segment assessment when media opacity limits view
76513	Anterior segment ultrasound (UBM)	Ciliary body, plateau iris, angle imaging
76514	Corneal pachymetry	Central corneal thickness measurement

Other Diagnostic Tests

CPT	Description	Notes
92020	Gonioscopy	Anterior chamber angle evaluation; glaucoma, uveitis
92060	Sensorimotor examination	Ocular motility, strabismus workup
92100	Serial tonometry	IOP monitoring over time
92285	External ocular photography	Lids, cornea, conjunctiva, iris documentation
92228	Screening dark adaptation measurement (new 2026)	Rod recovery intercept time; AMD risk screening
92025	Corneal topography	Keratoconus, contact lens fitting, pre-LASIK

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In-Office and Minor Procedures

Injections

CPT	Description	Notes
67028	Intravitreal injection of pharmacologic agent	Anti-VEGF (ranibizumab, bevacizumab, aflibercept, faricimab), intravitreal steroids; most common ophthalmic procedure in retina
68200	Subconjunctival injection	Periocular steroid or antibiotic delivery
67500	Retrobulbar injection	Anesthetic or steroid — retrobulbar space
67505	Peribulbar injection	Peribulbar anesthetic
J0178 / J0179	Drug codes (HCPCS)	Report appropriate J-code for the specific anti-VEGF drug administered with 67028

Anterior Segment Procedures

CPT	Description	Notes
65800	Paracentesis of anterior chamber	Anterior chamber tap; culture/drainage of hypopyon or aqueous
65810	Paracentesis of anterior chamber with vitreous removal and/or anterior hyaloid membrane discission
65435	Removal of corneal epithelium	Debridement for recurrent erosion, culture
65900	Removal of epithelial downgrowth
65855	Laser trabeculoplasty (SLT or ALT)	Open-angle glaucoma; selective or argon laser

Eyelid Procedures

CPT	Description	Notes
67800	Excision of chalazion, single	In-office or minor OR
67801	Excision of chalazion, multiple, same lid
67805	Excision of chalazion, multiple, different lids
67840	Excision of lesion of eyelid	Skin tag, papilloma, benign lesion
67700	Blepharotomy, drainage of abscess, eyelid
67710	Severing of tarsorrhaphy
67820	Correction of trichiasis, epilation by forceps only

Lacrimal System

CPT	Description	Notes
68761	Closure of lacrimal punctum by plug	Punctal plug insertion for dry eye
68801	Dilation of lacrimal punctum, with or without irrigation
68810	Probing of nasolacrimal duct
68815	Probing of nasolacrimal duct with insertion of tube or stent

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Laser Procedures

CPT	Description	Notes
66761	Iridotomy/iridectomy by laser surgery — per session	Laser peripheral iridotomy (LPI) for angle closure glaucoma
66821	Discission of secondary membranous cataract by laser surgery (YAG capsulotomy)	Posterior capsular opacification post-cataract
67210	Photocoagulation, retinal lesion (other than macular degeneration)	Focal laser treatment
67228	Photocoagulation of retinal lesion, extensive — panretinal photocoagulation (PRP)	Proliferative diabetic retinopathy, retinal vein occlusion
67229	Photocoagulation, retinal lesion, new vessels
67145	Prophylaxis of retinal detachment — cryotherapy or laser, 1 or more sessions	Lattice degeneration treatment

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Cataract Surgery

CPT	Description	Notes
66984	Extracapsular cataract removal with intraocular lens prosthesis, 1 stage	Standard phacoemulsification with IOL — most common cataract code
66985	Insertion of intraocular lens prosthesis (secondary implant)	Secondary IOL insertion
66986	Exchange of intraocular lens	IOL exchange
66830	Removal of secondary membranous cataract with corneal section	Open-sky posterior capsulotomy
66850	Removal of lens material, pars plana approach	Combined with vitrectomy
66982	Extracapsular cataract removal — complex	Use when significant comorbidity/complexity increases difficulty
66987	Extracapsular cataract removal with complex cataract + extended depth of focus or multifocal IOL
0996T	Insertion/scleral fixation of capsular bag prosthesis with IOL (new 2026 Cat III)	New 2026

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Glaucoma Surgery

CPT	Description	Notes
66170	Fistulization of sclera for glaucoma — trabeculectomy	Traditional bleb-forming surgery
66172	Fistulization of sclera, with scarring	Trabeculectomy in scarred/previously operated eye
66174	Trabeculostomy ab interno (MIGS — minimally invasive glaucoma surgery)	e.g., Kahook dual blade, trabectome
66175	Trabeculostomy ab interno, with use of illuminated microcatheter	iTrack-type MIGS
0671T	Insertion of anterior segment drainage device without external reservoir, internal approach	iStent inject-type MIGS (Category III)
1012T	Motorized ab interno trephination of scleral or trabecular meshwork (new 2026 Cat III)	New 2026

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Retina and Vitreous Surgery

CPT	Description	Notes
67005	Removal of vitreous, anterior approach
67010	Removal of vitreous, pars plana approach — subtotal
67015	Aspiration or release of vitreous, subretinal or choroidal space
67025	Injection of vitreous substitute, pars plana or limbal approach
67036	Vitrectomy, mechanical, pars plana approach
67039	Vitrectomy + focal endolaser photocoagulation
67040	Vitrectomy + endolaser photocoagulation, panretinal
67107	Repair of retinal detachment — scleral buckling
67108	Repair of retinal detachment — vitrectomy
67113	Repair of complex retinal detachment
67115	Release of encircling material (scleral buckle removal)
67120	Removal of implanted material, posterior segment — anterior approach
67121	Removal of implanted material, posterior segment — pars plana
67218	Radiation by implantation of source, retina/choroid
67220	Destruction of localized lesion of choroid — photocoagulation
67225	Photocoagulation, age-related macular degeneration, subfoveal

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Strabismus Surgery

CPT	Description	Notes
67311	Strabismus surgery — resection or recession, one horizontal muscle
67312	Strabismus surgery — two horizontal muscles
67314	Strabismus surgery — one vertical muscle
67316	Strabismus surgery — two or more vertical muscles
67320	Transposition procedure
67331	Strabismus surgery on patient with previous surgery or injury

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Common Modifiers in Ophthalmology

Modifier	Description	Ophthalmology Use
-RT	Right eye	Laterality for unilateral procedures
-LT	Left eye	Laterality for unilateral procedures
-50	Bilateral procedure	Bilateral procedures billed on one claim line
-25	Significant separately identifiable E/M same day as procedure	E/M + injection (e.g., 67028 + 92012-25) on same day
-24	Unrelated E/M during post-op period	E/M during global period for unrelated condition
-57	Decision for surgery	E/M visit where surgery was decided, day of or before 90-day surgery
-58	Staged/related procedure during post-op period	Planned second-stage ocular procedure within global period
-78	Unplanned return to OR for complication	Return for post-op complication (e.g., post-cataract endophthalmitis requiring vitrectomy)
-79	Unrelated procedure during post-op period	Unrelated ocular or non-ocular procedure during global period
-22	Increased procedural services	Complex surgical case requiring substantially more work than typical

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NCCI Bundling Watchpoints (Ophthalmology-Specific)

• 92250 + 92133/92134: Fundus photography and OCT are mutually exclusive per NCCI for the same eye on the same date. Append modifier XU or 59 only when both are independently medically necessary and fully documented.
• 92201/92202 + posterior segment surgery: Extended ophthalmoscopy is bundled into posterior segment surgical procedures (67005-67229) when performed same-day. Extended ophthalmoscopy would normally not be reported pre-operatively same-day as an elective posterior segment procedure.
• 67028 (intravitreal injection) + E/M same day: Modifier 25 on the E/M is required to separately bill E/M on the same day as an intravitreal injection when the E/M represents a significant, separately identifiable service beyond the pre-injection evaluation.
• Bilateral eye procedures: When the same procedure is performed bilaterally at the same session, use modifier 50 or bill separately with RT/LT per payer instructions.

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Common ICD-10-CM Codes Cross-Reference for Ophthalmology

ICD-10-CM	Description
H20.051	Hypopyon, right eye
H20.011	Primary iridocyclitis, right eye
H20.013	Primary iridocyclitis, bilateral
H25.13	Age-related nuclear cataract, bilateral
H26.001	Unspecified infantile and juvenile cataract, right eye
H40.1110	Primary open-angle glaucoma, right eye, mild stage
H40.1130	Primary open-angle glaucoma, right eye, severe stage
H35.31	Nonexudative (dry) AMD, right eye
H35.32	Exudative (wet) AMD, right eye
H35.81	Retinal edema
H43.391	Vitreous degeneration, right eye
H52.13	Myopia, bilateral
H53.003	Unspecified amblyopia, bilateral
H10.9	Unspecified conjunctivitis
H11.001	Unspecified pterygium, right eye
H16.009	Unspecified corneal ulcer, right eye
H30.91	Unspecified chorioretinal inflammation, right eye
H44.001	Unspecified purulent endophthalmitis, right eye
B00.51	Herpesviral iridocyclitis
B02.32	Zoster iridocyclitis
D86.83	Sarcoid iridocyclitis

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Suggested Obsidian Linkouts

• H20.051 — Hypopyon, right eye
• Uveitis and Iridocyclitis - Clinical Overview
• Global Surgical Package MOC
• Global Surgery Period Modifiers - Comparison & Reference
• -25 (modifier 25 — critical for same-day injection + E/M)
• -22 (modifier 22 — complex ophthalmic surgical cases)
• -76 and -77 (repeat procedure modifiers — relevant for bilateral staged procedures)