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    v1.0.30
    OpenPayerBilling CodesEstablished Patient General Ophthalmological Services and ProceduresCPT cpt-92012-intermediate-ophthalmology-established-patient-exam
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    CPT 92012: Intermediate Ophthalmological Exam for Established Patient

    Medicare pays $94 and commercial payers pay $142 on average nationally for this procedure.

    CPT code 92012 describes an ophthalmological intermediate-level eye examination for an established patient, involving history, limited examination, and medical decision-making focused on evaluation and management of ocular conditions; the service type is an outpatient ophthalmology office evaluation for an established patient and the typical site of service is an ambulatory clinic or office setting.

    For related coverage guidance, see recent payer policy updates: Navigated Transcranial Magnetic Stimulation for Preoperative Brain Mapping, Navigated Transcranial Magnetic Stimulation for Preoperative Brain Mapping, Navigated Transcranial Magnetic Stimulation for Preoperative Brain Mapping.

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    National Reimbursement Benchmarks

    Medicare averages about $94.10 for CPT 92012, while BUCA’s mean commercial rate sits higher at $141.70, a difference of $47.60. This places BUCA well above Medicare on average, with the commercial mean closer to the mid-to-upper range among national payers and Medicare anchored near the lower-middle of the national distribution.

    Dispersion (P75 minus P25) highlights variability by payer: Blue Cross Blue Shield shows the widest interquartile spread at $73.00 ($211.60 − $138.60), followed by UnitedHealth Group at $63.50 ($133.50 − $69.80) and Cigna at $69.10 ($135.50 − $64.10). Aetna’s spread is $62.80 ($107.10 − $47.30). BUCA’s IQR is $69.50 ($174.60 − $105.10). Medicare’s P75 − P25 is relatively tight at $9.00 ($97 − $88).

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    National Payer Mean Reimbursement Rates

    State Reimbursement Rates

    State: Alaska1 / 51

    Rate by payer

    Clinical & Coding Specifications

    Clinical Context

    An established adult patient returns to an ophthalmologist's clinic for an intermediate eye examination coded as 92012. The patient was last seen by the same ophthalmology group 18 months ago for routine evaluation of presbyopia and mild glaucoma. At this visit the patient reports gradual difficulty with near work and intermittent blurring. The clinical workflow includes registration and verification of insurance (examples: Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, BUCA, Medicare), review of past ocular history and medications, measurement of visual acuity, binocular and refraction screening as indicated, intraocular pressure check, and targeted slit‑lamp and fundus examination focusing on previously documented glaucoma changes and new visual complaints. Diagnostic testing (eg, external ocular photography 92285) may be ordered if warranted. The physician documents an expanded problem‑focused history and examination with medical decision making of low to moderate complexity, consistent with an intermediate established‑patient ophthalmological evaluation coded as 92012. Visit documentation includes the reason for visit, interval history, pertinent positives/negatives, exam findings, assessment (eg, H52.4, H40.9, H53.9), and any treatment changes or diagnostic orders. Typical site of service is an outpatient ophthalmology clinic or ambulatory surgical center when related procedures are performed. Typical service type is an intermediate ophthalmologic medical examination and evaluation for an established patient.

    Related CPT Codes

    Related Modifiers

    8 rows

    ModifierDescriptionWhen to Use
    25CPT modifier 25 indicates that on the same day as another procedure or service, the same physician or other qualified health care professional provided a significant, separately identifiable…- When to apply: Use modifier 25 only on an E/M code to indicate the same provider delivered a significant, separately identifiable E/M service on the same day as another procedure or service — i.e.,…
    59Modifier 59 indicates a distinct procedural service when two procedures that are not normally billed together are clinically and procedurally separate. The CPT definition (as reiterated by CMS)…- Use modifier -59 to report a distinct procedural service when documentation supports that the procedure reported is not normally billed together with another service on the same day because of a…
    26Modifier 26 (Professional Component) identifies and bills only the professional portion of a split service — the physician’s interpretation, report, and medical judgment — when the technical…- Use CPT Modifier -26 when you are billing only the professional component (PC) of a split‑bill eligible service—i.e., you performed the physician interpretation, medical judgment and prepared a…
    52Modifier ‑52 (Reduced Services) indicates that a service or procedure was partially reduced or omitted at the provider’s discretion, allowing reporting of the basic procedure number with a qualifier…- Use modifier -52 when a physician or qualified health professional electively reduces or omits part of a procedure or service (for example, performing fewer required views or omitting a portion of…
    53Modifier 53 (Discontinued Procedure) signals that a surgical or diagnostic service was begun by the physician but terminated because of extenuating circumstances that threatened the patient’s…- Use modifier -53 when a physician/qualified healthcare professional has started a surgical or diagnostic procedure (e.g., anesthesia administered, incision or scope insertion) and then discontinues…
    57CPT® modifier -57 (“Decision for Surgery”) is appended to an Evaluation and Management (E/M) service when that encounter results in the initial decision to perform a major surgery (a procedure with a…- Use modifier 57 when an E/M service provided by the same provider (or same tax ID) on the day of or the day before a major surgical procedure (90‑day global period) results in the initial decision…
    24Modifier 24 denotes an unrelated evaluation and management (E/M) service performed by the same physician or qualified healthcare professional during a postoperative global period. Per CPT guidance,…- Use modifier 24 when you report an evaluation and management (E/M) service performed by the same physician or same-specialty group during a procedure’s postoperative global period that is unrelated…
    95Modifier 95 indicates that a service was provided via synchronous, real‑time audio‑video telehealth rather than in‑person. Per CMS, AAPC and professional associations, append modifier 95 to claim…- Use modifier 95 to indicate a service was furnished via synchronous, real‑time audiovisual telehealth (a live audio‑video conference between patient and provider) rather than in‑person. - Pair…

    Related Provider Taxonomies

    8 rows

    Taxonomy Code
    207W00000X
    152W00000X
    207WX0009X
    251J00000X
    204R00000X
    251V00000X
    347E00000X
    363L00000X

    Related Payer Policy Updates

    Specialty: Neurology/Neurosurgery1 / 3

    10 rows

    PolicyPayerEffective Date
    Navigated Transcranial Magnetic Stimulation for Preoperative Brain Mappingpremerabluecrossofwashington2027-02-05
    Navigated Transcranial Magnetic Stimulation for Preoperative Brain Mappingpremerabluecrossofwashington2027-02-05
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    Calcitonin Gene-Related Peptide (CGRP) Inhibitors: Vyepti (eptinezumab-jjmr)Mass General Brigham Health Plan2027-01-04
    Clinical Review Criteria Intraoperative Neurophysiological Monitoring (IONM)Kaiser Permanente2027-01-01
    Open Neuroplasty Lumbar PlexusCigna2026-12-15
    Laser Interstitial Thermal TherapyCigna2026-11-15
    Remote Electrical Neuromodulation for Migraines (i.e., Nerivio®)bcbsvermont2026-11-01
    Artificial Cervical Intervertebral Discuniverahealthcare2026-10-15
    Lumbar Microdiscectomyuniverahealthcare2026-10-15

    Related Codes

    CPT-92014-COMPREHENSIVE-EYE-EXAM-ESTABLISHED-PATIENT

    CPT 92014: Comprehensive Eye Exam for Established Patient

    Frequently Asked Questions

    References

    1. 1.CPT® Codes and Descriptions. AAPC. Retrieved Aug 11, 2026.Maintains the CPT code set's official descriptions and guidelines, licensed from the American Medical Association, used as the definitional source for CPT codes on this page.
    2. 2.HCPCS Quarterly Update. Centers for Medicare & Medicaid Services (CMS). Retrieved Aug 11, 2026.CMS's quarterly release of HCPCS Level II codes and short/long descriptors, the source for HCPCS code definitions and update history.
    3. 3.ICD-10-CM Full Code List. Centers for Medicare & Medicaid Services (CMS). Retrieved Aug 11, 2026.CMS's complete ICD-10-CM diagnosis code list, used to cross-reference diagnosis codes associated with this procedure or service.
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    Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

    CPT Code
    Description
    Relationship to This Procedure
    92014Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive, established patient, 1 or more visitsMore comprehensive established‑patient exam; used when a full comprehensive evaluation is documented instead of the intermediate 92012.
    92285External ocular photography with interpretation and report for documentation of medical progressAncillary imaging that documents anterior/posterior findings; ordered during or after 92012 when photographic documentation is required.
    95874Needle electromyography for guidance in conjunction with chemodenervationUncommon in routine eye exams; may be related when chemodenervation procedures (eg, botulinum toxin for eyelid disorders) require EMG guidance.
    96372Therapeutic, prophylactic, or diagnostic injection; subcutaneous or intramuscularUsed when an injection (eg, periocular medication or systemic injection related to ocular therapy) is administered in association with the visit.
    J0585Injection, onabotulinumtoxina, 1 unitDrug code for onabotulinumtoxinA when used for ocular conditions (eg, blepharospasm) documented in the course of care following 92012.
    J0586Injection, abobotulinumtoxina, 5 unitsDrug code for abobotulinumtoxinA used similarly for eyelid movement disorders documented after evaluation.
    J0587Injection, rimabotulinumtoxinb, 100 unitsDrug code for rimabotulinumtoxinB when used therapeutically for eyelid or periocular spasm identified in the visit.
    J0588Injection, incobotulinumtoxina, 1 unitDrug code for incobotulinumtoxinA used in treatment of eyelid disorders following ophthalmic evaluation.