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CPT 92004: Comprehensive Ophthalmological Evaluation, New Patient

CPT code 92004 represents a comprehensive ophthalmological evaluation for a new patient that includes a full medical eye examination and initiation of a diagnostic and treatment program spanning one or more visits. Nationally, this code is fundamental for billing initial ophthalmic medical consultations and is used across ophthalmology practices, particularly for patients presenting with complex or undiagnosed ocular conditions. Key payers referenced include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise overview of reimbursement and billing context for CPT code 92004, comparisons to related evaluation codes for new and established patients, common clinical indications that map to the code, and payer coverage notes. The publication also summarizes typical sites of service and the clinical scope of a comprehensive new-patient ophthalmologic exam. This analysis is intended for coding professionals, billing managers, and clinicians seeking a clear national-level reference on the use and clinical context of CPT code 92004.

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Billing Code Overview

CPT code 92004 describes a comprehensive ophthalmological evaluation for a new patient in which the provider performs a full medical eye examination and initiates a diagnostic and treatment program for one or more visits. This service involves a broad assessment of ocular health, refraction as appropriate, and formulation of a diagnostic and therapeutic plan.

Service type: Comprehensive ophthalmological evaluation, new patient
Typical site of service: Ophthalmology clinic or ambulatory eye care setting

National Reimbursement Benchmarks

Nationally, Medicare’s average allowed amount of $155.20 sits below BUCA’s mean commercial rate of $232.60, indicating that commercial contracts on average reimburse substantially higher for CPT 92004 than the Medicare baseline. Blue Cross Blue Shield and UnitedHealth Group have the highest mean levels among listed payers, while Aetna and Cigna are lower but not at Medicare’s level; BUCA’s mean represents a middle-to-upper commercial position versus Medicare.

Dispersion measured as P75 minus P25 is widest for Blue Cross Blue Shield at $113.00 (P75 $335.00 minus P25 $220.20), followed by UnitedHealth Group at $108.40 (P75 $232.90 minus P25 $124.50). Cigna shows a spread of $119.80 (P75 $239.40 minus P25 $119.60) actually slightly larger, while Aetna is tighter with a spread of $84.90 (P75 $172.70 minus P25 $84.80) and BUCA’s interquartile range is $108.80 (P75 $283.60 minus P25 $172.80). Medicare’s interquartile range is $15.00 (P75 $160.00 minus P25 $145.00), the narrowest of the group.

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CPT 92004: Comprehensive Ophthalmological Evaluation, New Patient

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Billing Code Overview

Service type: Comprehensive ophthalmological evaluation, new patient
Typical site of service: Ophthalmology clinic or ambulatory eye care setting

National Reimbursement Benchmarks

National Payer Mean Reimbursement Rates

Clinical & Coding Specifications

Clinical Context

A 68-year-old new patient presents to an ophthalmology clinic with progressive difficulty reading and intermittent blurring in dim light. The provider conducts a comprehensive ophthalmological evaluation including history, measurement of visual acuity, manifest refraction, intraocular pressure measurement, slit-lamp anterior segment exam, dilated fundus examination, and baseline ancillary testing as indicated (e.g., visual field testing, optical coherence tomography). A diagnostic and treatment program is initiated which may include corrective lenses for presbyopia, glaucoma workup and treatment planning for suspected glaucoma, patient education, and scheduling of follow-up visits. Typical workflow occurs in an outpatient ophthalmology clinic or ambulatory surgical center where comprehensive new-patient evaluations are performed; services are commonly provided by an ophthalmologist, glaucoma specialist, or optometrist depending on scope of practice and state law. Documentation includes a detailed history, comprehensive exam findings, clinical decision making, assessment, and plan including any diagnostic testing ordered and treatment initiated. Payer interactions commonly involve verification of patient insurance benefits with carriers such as Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, BUCA, and Medicare prior to scheduling when needed.

Coding Specifications

Modifier	Description	When to Use
`25`	Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure	Use when a separate comprehensive ophthalmological exam is performed on the same day as another procedure and documentation supports independent E/M beyond the procedure
`26`	Professional component	Use when billing only the professional component of a diagnostic test (e.g., interpretation of imaging) when technical component billed separately
`TC`	Technical component	Use when billing only the technical component of a diagnostic service (e.g., OCT machine use) when professional interpretation billed separately
`52`	Reduced services	Use when the comprehensive exam is partially reduced or not completed due to patient factors or limitations
`53`	Discontinued procedure	Use when the exam or associated diagnostic testing is started but discontinued due to patient intolerance or emergent conditions
`59`	Distinct procedural service	Use to indicate services that are distinct and independent from other services on the same day when not appropriately described by other modifiers
`57`	Decision for surgery	Use when the comprehensive evaluation resulted in the decision to perform surgery within the global period and documentation supports preoperative decision-making
`24`	Unrelated E/M service by the same physician during postoperative period	Use when a new problem unrelated to a recent ophthalmic surgery is evaluated during the postoperative global period
`22`	Increased procedural services	Use when the work required to perform the comprehensive exam is substantially greater than typical and documentation supports the increased complexity
`95`	Synchronous telemedicine service rendered via real-time interactive audio and video	Use when the comprehensive evaluation is conducted via live telemedicine when payer accepts telehealth for ophthalmology
`50`	Bilateral procedure	Use when bilateral comprehensive evaluations are performed and payer requires bilateral modifier reporting
`LT`	Left side	Use when billing must designate left eye when laterality reporting is required by payer
`RT`	Right side	Use when billing must designate right eye when laterality reporting is required by payer
`XU`	Unusual non-overlapping service	Use when the service is distinct and not typically billed together with other services provided the documentation supports non-overlap

Taxonomy Code	Specialty	Notes
`207W00000X`	Ophthalmology Physician	Performs medical and surgical eye care including comprehensive evaluations for new patients
`152W00000X`	Optometrist	Provides comprehensive eye exams, refraction, and co-management of ocular disease per state scope of practice
`207WX0009X`	Glaucoma Specialist	Provides specialized evaluation and management when glaucoma is suspected or diagnosed

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`H52.4`	Presbyopia	Common age-related cause of near-vision difficulty prompting comprehensive refractive and functional assessment during a new-patient exam
`H40.9`	Unspecified glaucoma	Findings of elevated intraocular pressure or optic nerve changes during comprehensive exam require glaucoma workup and initiation of diagnostic/treatment plan
`H53.9`	Unspecified visual disturbance	Patients presenting with nonspecific visual symptoms undergo comprehensive evaluation to determine etiology and management
`H54.7`	Unspecified visual loss	Significant visual loss identified at presentation mandates comprehensive assessment and urgent diagnostic workup
`Z01.00`	Encounter for examination of eyes and vision without abnormal findings	Used when a comprehensive new-patient evaluation is performed and no ocular abnormality is found, documenting preventive/diagnostic exam outcome

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`92002`	Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; intermediate, new patient	Less comprehensive alternative for a new patient when a comprehensive exam (`92004`) is not medically necessary; used for focused/new-patient intermediate evaluations
`92012`	Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established patient	Equivalent intermediate-level service for established patients; used in follow-up visits after an initial comprehensive new-patient exam
`92014`	Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive, established patient, 1 or more visits	Used for comprehensive follow-up visits in established patients when continued comprehensive evaluation or management is required after the initial new-patient `92004` visit

CPT 92002: Intermediate Ophthalmological Evaluation, New Patient

References

1.CPT® Codes and Descriptions. AAPC. Retrieved Jul 29, 2026.
2.HCPCS Quarterly Update. Centers for Medicare & Medicaid Services (CMS). Retrieved Jul 29, 2026.
3.ICD-10-CM Full Code List. Centers for Medicare & Medicaid Services (CMS). Retrieved Jul 29, 2026.

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Clinical & Coding Specifications

Clinical Context

Coding Specifications

Modifier	Description	When to Use
`25`	Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure	Use when a separate comprehensive ophthalmological exam is performed on the same day as another procedure and documentation supports independent E/M beyond the procedure
`26`	Professional component	Use when billing only the professional component of a diagnostic test (e.g., interpretation of imaging) when technical component billed separately
`TC`	Technical component	Use when billing only the technical component of a diagnostic service (e.g., OCT machine use) when professional interpretation billed separately
`52`	Reduced services	Use when the comprehensive exam is partially reduced or not completed due to patient factors or limitations
`53`	Discontinued procedure	Use when the exam or associated diagnostic testing is started but discontinued due to patient intolerance or emergent conditions
`59`	Distinct procedural service	Use to indicate services that are distinct and independent from other services on the same day when not appropriately described by other modifiers
`57`	Decision for surgery	Use when the comprehensive evaluation resulted in the decision to perform surgery within the global period and documentation supports preoperative decision-making
`24`	Unrelated E/M service by the same physician during postoperative period	Use when a new problem unrelated to a recent ophthalmic surgery is evaluated during the postoperative global period
`22`	Increased procedural services	Use when the work required to perform the comprehensive exam is substantially greater than typical and documentation supports the increased complexity
`95`	Synchronous telemedicine service rendered via real-time interactive audio and video	Use when the comprehensive evaluation is conducted via live telemedicine when payer accepts telehealth for ophthalmology
`50`	Bilateral procedure	Use when bilateral comprehensive evaluations are performed and payer requires bilateral modifier reporting
`LT`	Left side	Use when billing must designate left eye when laterality reporting is required by payer
`RT`	Right side	Use when billing must designate right eye when laterality reporting is required by payer
`XU`	Unusual non-overlapping service	Use when the service is distinct and not typically billed together with other services provided the documentation supports non-overlap

Taxonomy Code	Specialty	Notes
`207W00000X`	Ophthalmology Physician	Performs medical and surgical eye care including comprehensive evaluations for new patients
`152W00000X`	Optometrist	Provides comprehensive eye exams, refraction, and co-management of ocular disease per state scope of practice
`207WX0009X`	Glaucoma Specialist	Provides specialized evaluation and management when glaucoma is suspected or diagnosed

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`H52.4`	Presbyopia	Common age-related cause of near-vision difficulty prompting comprehensive refractive and functional assessment during a new-patient exam
`H40.9`	Unspecified glaucoma	Findings of elevated intraocular pressure or optic nerve changes during comprehensive exam require glaucoma workup and initiation of diagnostic/treatment plan
`H53.9`	Unspecified visual disturbance	Patients presenting with nonspecific visual symptoms undergo comprehensive evaluation to determine etiology and management
`H54.7`	Unspecified visual loss	Significant visual loss identified at presentation mandates comprehensive assessment and urgent diagnostic workup
`Z01.00`	Encounter for examination of eyes and vision without abnormal findings	Used when a comprehensive new-patient evaluation is performed and no ocular abnormality is found, documenting preventive/diagnostic exam outcome

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`92002`	Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; intermediate, new patient	Less comprehensive alternative for a new patient when a comprehensive exam (`92004`) is not medically necessary; used for focused/new-patient intermediate evaluations
`92012`	Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established patient	Equivalent intermediate-level service for established patients; used in follow-up visits after an initial comprehensive new-patient exam
`92014`	Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive, established patient, 1 or more visits	Used for comprehensive follow-up visits in established patients when continued comprehensive evaluation or management is required after the initial new-patient `92004` visit

CPT 92002: Intermediate Ophthalmological Evaluation, New Patient

References

1.CPT® Codes and Descriptions. AAPC. Retrieved Jul 29, 2026.
2.HCPCS Quarterly Update. Centers for Medicare & Medicaid Services (CMS). Retrieved Jul 29, 2026.
3.ICD-10-CM Full Code List. Centers for Medicare & Medicaid Services (CMS). Retrieved Jul 29, 2026.

Published by

Trek Health powers OpenPayer with a leading commercial payer intelligence platform, seamlessly converting fragmented payer data into actionable insights for provider organizations.

OpenPayer

CPT 92004: Comprehensive Ophthalmological Evaluation, New Patient

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Billing Code Overview

National Reimbursement Benchmarks

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OpenPayer

CPT 92004: Comprehensive Ophthalmological Evaluation, New Patient

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Billing Code Overview

National Reimbursement Benchmarks

Clinical & Coding Specifications

Clinical Context

Coding Specifications

Related Diagnoses

Related CPT Codes

Related Codes

References

Clinical & Coding Specifications

Clinical Context

Coding Specifications

Related Diagnoses

Related CPT Codes

Related Codes

References