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92012

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🎯 CPT Code 92012: Intermediate eye exam, established patient

Short Definition

Ophthalmological services, medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established patient

Long Definition

CPT code 92012 describes an intermediate level ophthalmological examination and evaluation for an established patient. An established patient is defined as someone who has received professional services from the physician or another physician of the same specialty in the same group practice within the past three years. This code represents a focused medical examination of the eye and visual system that is more limited in scope than a comprehensive examination (92014) but more detailed than a minimal service. The intermediate exam typically addresses a specific problem or follow-up issue and includes initiation or continuation of a diagnostic and treatment program. The examination includes a problem-focused history, general medical observation, external ocular and adnexal examination, and other diagnostic procedures as indicated, which may include the use of mydriasis (pupil dilation) for ophthalmoscopic examination when medically necessary. This is NOT a time-based code; the level of service is determined by the components of the examination performed and documented, not by the amount of time spent with the patient.

Area of Body

Eye and visual system, including:

  • External ocular structures (eyelids, conjunctiva, cornea, sclera)
  • Anterior segment (anterior chamber, iris, lens)
  • Intraocular pressure
  • Pupillary responses
  • Ocular motility (as relevant to presenting problem)
  • Posterior segment (optic nerve, retina, macula, vitreous) when indicated with ophthalmoscopy
  • Visual acuity
  • Anterior segment structures via slit lamp when indicated

Service Components

Included Services (Intermediate Examination Elements):

According to CPT guidelines, an intermediate examination typically includes:

  • History: Problem-focused history related to chief complaint or follow-up issue
  • General medical observation: Overall patient assessment relevant to eye condition
  • External ocular and adnexal examination: Lids, lashes, lacrimal system, conjunctiva, cornea, anterior chamber, iris
  • Basic ophthalmoscopic examination: When indicated and appropriate for the presenting problem
  • Other diagnostic procedures as indicated:
    • Visual acuity testing
    • Tonometry (IOP measurement) when indicated
    • Pupil examination when relevant
    • Gross visual fields when relevant
    • Slit lamp examination when indicated
    • Mydriasis (dilation) may be performed if medically necessary for the examination
  • Medical decision making appropriate for the presenting problem
  • Initiation or continuation of diagnostic and treatment program

Key Distinction from Comprehensive (92014):

  • Intermediate exam (92012) includes some but not all of the elements of a comprehensive exam
  • Typically 3-8 examination elements (vs 12+ for comprehensive)
  • Problem-focused rather than complete evaluation
  • Appropriate for established patients with specific issues or routine follow-ups

Excludes:

  • Comprehensive ophthalmological examination (use 92014 for established patients)
  • New patient intermediate examination (use 92002)
  • Special ophthalmological services requiring separate procedures (92018-92499)
  • Refractive services (92015 - bill separately, typically non-covered)
  • Extended ophthalmoscopy (92225-92226)
  • Separate diagnostic testing procedures:
  • Contact lens services (92310-92326)
  • Orthoptic/pleoptic training (92065)
  • E/M services using 99212-99215 codes (mutually exclusive same encounter)

Separately Billable When Appropriate:

  • Diagnostic testing beyond basic examination (visual fields, OCT, fundus photos, etc.)
  • Refractive services (92015)
  • Special ophthalmological services (various 92xxx codes)
  • Minor procedures performed same day (with appropriate modifiers if needed)
  • Injections (intravitreal, subconjunctival, etc.)

RVU Information

Work RVU (wRVU): 0.92
Facility Total RVU: Approximately 1.45
Non-Facility Total RVU: Approximately 2.01
Global Days: XXX (no global period; this is an E/M service, not a surgical procedure)
Medicare Status: Active/Payable
2026 Medicare National Average:

  • Facility: Approximately $47-50
  • Non-Facility: Approximately $65-71
    (Varies by geographic locality and MAC)

RVU Comparison to Related Codes:

  • 92012 (intermediate established): 0.92 wRVU
  • 99213 (E/M established level 3): 0.97 wRVU (comparable)
  • 92014 (comprehensive established): 1.42 wRVU (higher, more extensive)
  • 92002 (intermediate new patient): 0.92 wRVU (same work, but different patient status)
  • 92004 (comprehensive new patient): 2.77 wRVU (significantly higher)

Historical Note:

Prior to 2007, there was a significant RVU differential favoring 92012 over 99213 due to calculation error. This was corrected, though 92012 still has slight advantage in non-facility settings.

HCC Status

Not Applicable - HCC coding applies only to ICD-10 diagnosis codes, not CPT procedure codes

Assistant Surgeon Status

Assistant Payable: Not Applicable

CPT 92012 is an evaluation and management (examination) service, not a surgical procedure. The concept of assistant surgeon does not apply to E/M services or examinations. Assistant surgeon modifiers (80, 81, 82, AS) are never used with examination codes.

Common Modifiers

ModifierDescriptionUsage FrequencyApplicationNotes
-24Unrelated E/M during postoperative periodLow-ModerateWhen exam unrelated to recent surgeryMust document unrelated nature
-25Significant, separately identifiable E/MModerate-HighWhen E/M same day as procedureRequired by many payers
-57Decision for surgeryLowWhen exam results in decision for major surgeryFor surgeries with 90-day global
-59Distinct procedural serviceRareVery rarely applicable to E/MUsually not appropriate for 92012
-32Mandated servicesRareRequired exam by another entitySecond opinion requests
-AIPrincipal physician of recordRareSpecific teaching hospital scenariosLimited use

Critical Modifier Information:

Modifier 25 (Most Common with 92012):

  • Used when providing significant, separately identifiable E/M service on same day as procedure
  • Example: Patient comes for follow-up exam (92012) AND gets intravitreal injection same visit
  • Must document that E/M was separately identifiable:
    • Addressed different issue, OR
    • Significant evaluation beyond what’s normally part of procedure
  • Required by most payers when billing E/M with procedure same day
  • Documentation should support separate service

Modifier 24:

  • Used during post-operative global period for UNRELATED problem
  • Example: Patient 30 days after cataract surgery (still in 90-day global) presents with new problem in other eye
  • Must clearly document unrelated nature in chart
  • Diagnosis code should be different from surgical diagnosis

Modifier 57:

  • Used when E/M results in decision for major surgery (90-day global)
  • Example: Exam reveals need for vitrectomy, surgeon schedules surgery
  • CMS requires modifier 57 for decision visit day before or day of major surgery
  • Note: Minor procedures (0 or 10-day global) use modifier 25, not 57

Modifiers NOT Typically Used with 92012:

  • 50 (bilateral): E/M services are not unilateral/bilateral procedures
  • 51 (multiple procedures): Not applicable to E/M codes
  • 76, 77 (repeat procedures): E/M visits are not “repeats” of procedures
  • 22 (increased services): Not applicable to E/M codes
  • 52 (reduced services): Not applicable to E/M codes
  • RT, LT, E1-E4 (anatomic): Not used with E/M codes

Common Associated CPT Codes

CPT CodeDescriptionRelationship to 92012Billing Considerations
92014Comprehensive eye exam, establishedHigher level alternativeUse when full 12-element exam performed
92002Intermediate eye exam, new patientNew patient equivalentSame level, different patient status
92004Comprehensive eye exam, new patientNew patient higher levelMore extensive new patient exam
92015Determination of refractive stateCommonly billed togetherTypically patient responsibility
99212-99215E/M established patientAlternative E/M codesCannot bill with 92012 same encounter
92081-92083Visual field testingCommonly associatedSeparately billable
92132OCT anterior segmentDiagnostic testSeparately billable same day
92133OCT optic nerveDiagnostic testSeparately billable same day
92134OCT retinaDiagnostic testSeparately billable same day
92250Fundus photographyDiagnostic testSeparately billable (may have NCCI considerations)
92020GonioscopyDiagnostic testSeparately billable
67028Intravitreal injectionProcedure with E/MUse modifier 25 on 92012
66984Cataract surgerySurgical procedurePre-op exam or decision visit
67210Laser photocoagulationProcedureUse modifier 25 if separately identifiable E/M
65855Laser trabeculoplastyProcedureUse modifier 25 if significant separate E/M
92310-92326Contact lens servicesFitting servicesDifferent encounter typically

Common Service Combinations:

Routine Follow-Up with Diagnostic Testing:

  • 92012 - Intermediate exam
  • 92083 - Visual field testing (glaucoma follow-up)
  • Commonly billed together for glaucoma patients

Exam with Injection:

  • 92012-25 - Intermediate exam with modifier 25
  • 67028 - Intravitreal injection (macular degeneration, diabetic retinopathy)
  • Modifier 25 required to indicate E/M was separate from injection

Exam with OCT Imaging:

  • 92012 - Intermediate exam
  • 92133 or 92134 - OCT imaging
  • Both separately payable

Pre-operative Evaluation:

  • 92012-57 (if decision for surgery)
  • Followed by surgical code (e.g., 66984 cataract surgery)
  • Modifier 57 if exam day before or day of major surgery

Code Tree/Hierarchy

CPT Manual Section: Medicine (90000-99999)
Subsection: Ophthalmology (92002-92499)
Major Category: General Ophthalmological Services (92002-92014)
Service Level: Intermediate (Level 2)
Patient Status: Established Patient
Code: 92012

General Ophthalmological Services Code Family:

General Ophthalmological Services (92002-92014)
├── New Patient Services
│   ├── 92002 - Intermediate examination, new patient
│   └── 92004 - Comprehensive examination, new patient
│
└── Established Patient Services
    ├── 92012 - Intermediate examination, established patient ◄ Current Code
    └── 92014 - Comprehensive examination, established patient

Code Selection Decision Tree:

Patient Presenting for Eye Examination?
│
├── Determine Patient Status
│   │
│   ├── NEW PATIENT (not seen by provider or same specialty in group within 3 years)
│   │   ├── Focused/Problem-oriented exam → 92002
│   │   └── Complete comprehensive exam → 92004
│   │
│   └── ESTABLISHED PATIENT (seen within past 3 years)
│       │
│       ├── INTERMEDIATE exam (3-8 elements, problem-focused) → 92012 ◄ Current
│       └── COMPREHENSIVE exam (all 12 elements, complete evaluation) → 92014
│
└── Alternative: Use E/M Codes Instead
    ├── New patient → 99202-99205
    └── Established patient → 99212-99215

Note: Cannot bill both ophthalmology codes (92xxx) AND E/M codes (99xxx) same encounter

Key Elements Determining 92012 vs 92014:

Use 92012 (Intermediate) When:

  • Follow-up visit for specific problem
  • Problem-focused evaluation
  • Routine monitoring visit (stable glaucoma, diabetic retinopathy screening, post-op check)
  • Limited examination addressing chief complaint
  • 3-8 examination elements documented
  • Does not require all comprehensive elements

Use 92014 (Comprehensive) When:

  • Complete, thorough eye examination
  • Annual comprehensive exam
  • Complex patient requiring full evaluation
  • New problem requiring extensive work-up
  • All 12 comprehensive exam elements documented:
    1. Chief complaint
    2. History of present illness
    3. Past medical/ocular history
    4. Family history
    5. Social history
    6. Review of systems
    7. General medical observation
    8. External examination
    9. Ophthalmoscopic examination
    10. Slit lamp examination
    11. Other diagnostic procedures
    12. Impression and plan

Alternative: Ophthalmology Codes (92xxx) vs E/M Codes (99xxx):

Physicians may choose between:

  • Ophthalmology-specific codes: 92002, 92004, 92012, 92014
  • General E/M codes: 99202-99205 (new), 99212-99215 (established)

Cannot bill both types same encounter - must choose one

Consider 92012 when:

  • Eye-focused examination
  • Ophthalmologic techniques integral to visit
  • RVU comparison favorable (92012: 0.92 vs 99213: 0.97)

Consider E/M codes (99213, 99214) when:

  • Medical complexity high
  • Significant time spent counseling
  • Multiple medical problems addressed
  • Higher level E/M (99214, 99215) may pay more than 92014

Coding Examples

Example 1: Glaucoma Follow-Up

Patient Presentation: 68-year-old established patient with primary open-angle glaucoma on latanoprost, presents for 6-month follow-up.

History:

  • No new visual complaints
  • Compliant with drops
  • No side effects from medication

Examination Performed:

  • Visual acuity: 20/25 OU (stable)
  • Intraocular pressure: 14 mmHg OD, 15 mmHg OS (at target)
  • External examination: Normal
  • Slit lamp: Anterior chamber deep and quiet OU
  • Dilated fundus examination: Optic nerves stable, CDR 0.7 OU, no hemorrhages
  • OCT optic nerve performed showing stable RNFL thickness

Assessment: Primary open-angle glaucoma, well-controlled on current medication

Plan: Continue latanoprost, return in 6 months, check visual fields next visit

Coding:

  • 92012 - Intermediate eye examination, established patient
  • 92133 - OCT optic nerve (separately billable)

Diagnosis:

  • H40.1113 - Primary open-angle glaucoma, bilateral, moderate stage
  • Z79.899 - Long-term use of other medications

Documentation Supports 92012:

  • Problem-focused visit for specific condition (glaucoma)
  • Established patient
  • Key elements documented: history, IOP, external exam, dilated fundus exam, OCT
  • Did not require comprehensive exam; focused on glaucoma status
  • Intermediate level appropriate

Example 2: Diabetic Retinopathy Screening

Patient: 55-year-old established patient with Type 2 diabetes, annual diabetic eye screening.

History:

  • Type 2 diabetes for 10 years
  • HbA1c 7.2% (fair control)
  • No visual complaints
  • Last eye exam 13 months ago

Examination:

  • Visual acuity: 20/20 OU
  • External examination: Normal
  • Pupil examination: Normal
  • Dilated fundus examination:
    • Few microaneurysms and dot hemorrhages OU
    • No macular edema
    • No neovascularization
  • Fundus photographs taken

Assessment: Mild non-proliferative diabetic retinopathy OU, no macular edema

Plan: Return in 6 months for monitoring, reinforce glucose control

Coding:

  • 92012 - Intermediate examination, established
  • 92250 - Fundus photography with interpretation

Diagnosis:

  • E11.329 - Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema
  • E11.9 - Type 2 diabetes mellitus without complications (if separate documentation needed)

Rationale for 92012:

  • Screening/surveillance visit for known condition
  • Problem-focused: Diabetic retinopathy assessment
  • Elements: Visual acuity, external exam, dilated fundus exam, fundus photos
  • Intermediate level appropriate for routine diabetic screening

Example 3: Post-Operative Cataract Check

Patient: 72-year-old established patient, 1-week post-operative visit after uncomplicated cataract surgery right eye.

History:

  • Cataract surgery 7 days ago
  • Vision improving
  • No pain, no flashes/floaters
  • Using post-op drops as directed

Examination:

  • Visual acuity: 20/30 OD (improved from 20/60 pre-op), 20/40 OS
  • IOP: 14 mmHg OD, 16 mmHg OS
  • External: Incision well-healed, no injection
  • Slit lamp: Anterior chamber deep, no cells, IOL well-positioned
  • Dilated exam OD: Retina attached, no concerns

Assessment: Normal post-operative recovery status post cataract extraction

Plan: Continue post-op medications, taper over next 2 weeks, return in 3 weeks

Coding:

  • 99024 - Postoperative follow-up visit, included in global surgical package (NO CHARGE)
  • Do NOT bill 92012 (included in 90-day global surgical package for 66984)

Diagnosis:

  • Z98.89 - Other specified postprocedural states
  • H26.9 - Unspecified cataract (if needed for context)

Key Point: Post-operative visits within global period are included in surgical fee; do NOT bill separate E/M or 92012.

Exception: If patient presents with UNRELATED problem during global period, may bill 92012-24 with different diagnosis.

Example 4: Exam with Intravitreal Injection

Patient: 80-year-old established patient with wet age-related macular degeneration, scheduled for intravitreal Eylea injection.

History:

  • Wet AMD on monthly injections
  • Vision stable since last injection
  • No new symptoms

Examination (Pre-Injection):

  • Visual acuity: 20/60 OD (unchanged), 20/25 OS
  • IOP: 16 mmHg OD, 17 mmHg OS
  • External: Normal
  • Dilated fundus exam OD: Subretinal fluid present, mild improvement from prior
  • OCT macula OD: Central subfield thickness 315 microns (decreased from 365)

Assessment: Wet AMD OD responding to anti-VEGF therapy

Plan: Proceed with intravitreal Eylea injection today, return in 4 weeks

Procedure: Intravitreal injection Eylea 2mg performed without complication

Coding:

  • 92012-25 - Intermediate exam with modifier 25
  • 67028 - Intravitreal injection drug delivery

Alternative (Depending on Payer):

  • Some payers may not require modifier 25 if E/M clearly documented separately
  • Some payers bundle minimal E/M into injection and only pay if significant separate service

Diagnosis:

  • H35.3210 - Exudative age-related macular degeneration, right eye, stage unspecified

Modifier 25 Documentation Requirements:

  • Must document that examination was separately identifiable from injection
  • Pre-injection assessment of response to therapy
  • OCT imaging showing change in retinal thickness
  • Medical decision-making regarding continuation of therapy
  • Should go beyond minimal evaluation required for injection

Documentation Tip: Many payers scrutinize modifier 25 use with injections. Ensure documentation clearly supports separate E/M service beyond standard pre-injection check.

Example 5: New Problem During Routine Follow-Up

Patient: 65-year-old established patient presents for routine glaucoma follow-up but also reports new onset of flashes and floaters in left eye for 2 days.

History:

  • Glaucoma: Stable on timolol
  • New complaint: Flashes and floaters OS for 48 hours, shower of floaters this morning

Examination:

  • Visual acuity: 20/25 OU
  • IOP: 14 mmHg OU (stable for glaucoma)
  • Dilated fundus exam:
    • OD: Stable glaucomatous changes
    • OS: Horseshoe retinal tear at 2:00 position with localized subretinal fluid
  • Additional time spent examining peripheral retina with scleral depression

Assessment:

  1. Retinal tear with localized detachment, left eye (new, urgent)
  2. Primary open-angle glaucoma, stable

Plan:

  • Urgent laser photocoagulation to retinal tear scheduled
  • Continue glaucoma medications
  • Close follow-up for both conditions

Coding:

  • 92014 - May consider comprehensive due to extended examination for new problem
  • OR 92012 - Intermediate if documented as problem-focused on two issues
  • 92225 - Extended ophthalmoscopy with retinal drawing (if documented)

Alternative if Laser Performed Same Day:

  • 92012-57 (or 92014-57) - Decision for laser surgery
  • 67145 - Prophylaxis of retinal detachment, laser (if performed)

Diagnosis:

  • H33.311 - Retinal break with detachment, right eye (primary, more urgent)

Coding Decision:

  • If exam addresses both problems but focused primarily on new retinal issue: 92012
  • If complete comprehensive re-evaluation of both eyes performed: 92014
  • Document medical necessity for level selected
  • Modifier 57 if laser surgery planned same day or next day

Example 6: Contact Lens Complication

Patient: 28-year-old established patient, soft contact lens wearer, presents with red, painful right eye for 1 day.

History:

  • Wears soft contact lenses daily
  • Slept in lenses last night (not recommended)
  • Awoke with right eye red and painful
  • Removed lens immediately

Examination:

  • Visual acuity: 20/30 OD (reduced), 20/20 OS
  • External: Right eye moderately injected
  • Slit lamp examination OD:
    • Central corneal infiltrate 2mm with surrounding edema
    • Epithelial defect with fluorescein staining
    • Anterior chamber: 1+ cells
  • Slit lamp OS: Normal
  • Assessment: Contact lens-associated keratitis, rule out infectious etiology

Cultures obtained, treatment initiated

Plan:

  • Stop contact lens wear
  • Fortified antibiotic drops q1h
  • Follow-up daily until improvement
  • Contact lens refit after resolution

Coding:

  • 92012 - Intermediate examination, established patient

Diagnosis:

  • H16.239 - Contact lens-associated keratitis, unspecified eye (specify right)
  • H16.011 - Central corneal ulcer, right eye

Rationale for 92012:

  • Focused examination for acute problem
  • Problem-oriented: Contact lens com

Graph View

Recent Notes