Eye Care Coding Reference
CPT 92004 new patient eye exam.
What a comprehensive eye exam for a new patient includes, the 3-year rule that decides new versus established, how it compares with 92002, 92014 and 99204, and how refraction and routine exams are handled. Last reviewed October 2026.
In one paragraph
The comprehensive exam for new patients.
CPT 92004 is the comprehensive eye exam for a new patient, meaning someone with no professional service from the doctor, or a same-specialty doctor in the same group, in the past 3 years. It is a general evaluation of the whole visual system that starts a diagnostic or treatment plan, and it can be completed over more than one visit. Refraction is separate and reported with 92015, which Medicare does not cover. The intermediate new patient code is 92002, the established patient version is 92014, and 99204 is the E/M alternative when medical decision making drives the visit. Descriptions on this page are Vision Rescue summaries, not the official CPT descriptor.
92004 at a glance
- Patient type: new, no visit in 3 years
- Established version: 92014
- Intermediate new patient version: 92002
- Refraction: not included, reported as 92015
- Dilation: performed when indicated, not a fixed rule
- A frequent target of new patient audits
Who counts as a new patient.
Medicare's rule is the one most payers follow. A patient is new if they have had no face-to-face professional service from the doctor, or from another doctor of the same specialty in the same group, within the past 3 years.
Usually established
- Seen by any same-specialty doctor in the group within 3 years
- Seen by a retiring doctor whose patients a new colleague takes over
- Following their doctor to a new practice
- Seen by a nurse practitioner or physician assistant working with the doctor, under many payers' rules
Usually new
- No visit with the doctor or the group's same-specialty doctors in 3 years
- Last seen more than 3 years ago
- Seen before only by a doctor of a different specialty, under Medicare's specialty codes
- Seen in a different, unrelated practice
Medicare claims systems recognize ophthalmology and optometry as separate specialties and do not recognize subspecialties. Some commercial plans treat optometry and ophthalmology in one group as the same specialty, and many practices treat in-group referrals as established to avoid confusing patients. CMS recovery auditors review new patient eye codes billed for patients seen within 3 years.
92002 or 92004.
Both codes are for new patients. The difference is the scope of the exam.
| Feature | 92002 intermediate | 92004 comprehensive |
|---|---|---|
| Scope | Evaluation of a specific new or existing problem | Evaluation of the complete visual system |
| Exam elements | Fewer than the full set; AAO guidance points to at least 3 | The full set of elements on the AAO checklist |
| Diagnostic or treatment program | Started as needed | Always started |
| Visits | One encounter | Can span one or more visits |
| Typical fit | A new patient seen for a single focused problem | A full first exam or full workup of a complaint |
What a comprehensive exam includes.
CPT describes the comprehensive exam as a general evaluation of the complete visual system that always includes starting a diagnostic or treatment program. Eye codes are not scored like E/M visits, so auditors look for these elements.
Exam elements on the AAO checklist
- Chief complaint, history and general medical observation
- Visual acuity and gross or confrontation visual fields
- Extraocular motility, pupils and iris
- Adnexa, conjunctiva, cornea, anterior chamber and lens
- Intraocular pressure
- Optic nerve, retina and vessels
Starting a diagnostic or treatment program
- Prescribing medication, glasses or contact lenses
- Ordering tests, imaging or lab work
- Referral or consultation
- Recommending or scheduling a procedure or surgery
- Scheduling follow-up care
The AAO advises dilating when medically necessary and documenting the reason when it is not done. The AOA notes that CPT says these exams often include dilation, which does not make it mandatory, though some payers require it for certain patients. When a patient declines dilation, the AOA suggests documenting the reason and offering a later visit, since a comprehensive exam can span more than one session.
92004 or 92014.
These two codes describe the same comprehensive exam. Patient status is the only difference.
| Patient | Intermediate | Comprehensive |
|---|---|---|
| New: no visit with the doctor or same-specialty group in 3 years | 92002 | 92004 |
| Established: seen within 3 years | 92012 | 92014 |
Because a patient can be new only once in a 3-year window, a second 92004 for the same patient within 3 years from the same doctor or same-specialty group is a common audit finding.
92004 or 99204.
A new patient can be reported with an eye code or an E/M code. The documentation and the payer's rules decide which fits.
| Point | 92004 eye code | 99204 E/M code |
|---|---|---|
| How the level is set | By the scope of the exam, not by complexity | By medical decision making or total time |
| What drives the visit | A full eye exam | The problems addressed, data reviewed and risk |
| Same day as the other | Not reported with an E/M visit | Includes the general eye exam |
| New patient rule | Same 3-year rule | Same 3-year rule |
Under the 2026 Medicare NCCI policy manual, general ophthalmological services are not reported separately on the same date as an E/M visit. Coding educators advise choosing by documentation and payer policy first, never by fee schedule alone.
Refraction, Medicare and vision plans.
Refraction is not part of 92004. Whether the exam is paid as routine or medical depends on the payer, the diagnosis and the reason for the visit.
Original Medicare
- Covers 92004 when it is tied to a symptom, complaint or eye disease
- Excludes exams for prescribing or changing glasses or contacts
- Excludes refraction, 92015, for any reason
- Covers a yearly diabetic eye exam and glaucoma screening for high-risk patients
- Does not accept the routine exam codes S0620 and S0621
Vision and commercial plans
- Many vision plans pay a routine exam that includes refraction
- Some plans use S0620 for a routine new patient exam
- Routine benefits are often limited to one exam every 12 or 24 months
- Payers may deny 92004 billed with only a routine or refractive diagnosis
The code itself did not change. Medicare's 2026 fee schedule applied a 2.5 percent efficiency adjustment to many non-time-based services, but eye exam codes and E/M visits were exempt, and office visit payments rose slightly for the year.
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Questions about CPT 92004
What is CPT code 92004?
It is the code for a comprehensive eye exam for a new patient. The exam evaluates the whole visual system and starts a diagnostic or treatment plan, and it can be completed over more than one visit.
What is the difference between 92002 and 92004?
Both are for new patients. 92004 is a comprehensive exam of the complete visual system. 92002 is an intermediate exam focused on a specific problem with a more limited set of exam elements.
What is the difference between 92004 and 92014?
They describe the same comprehensive exam. 92004 is for a new patient with no visit to the doctor or same-specialty group in 3 years, and 92014 is for an established patient.
How often can 92004 be billed?
A patient is new only if they have had no professional service from the doctor or a same-specialty doctor in the group within 3 years, so the same practice and specialty generally cannot report 92004 for that patient again inside that window.
Is 92004 covered by Medicare?
Yes, when the exam is tied to a symptom, complaint or eye disease. Original Medicare does not cover exams done only to prescribe glasses or contacts, and it does not cover refraction.
Can 92004 and 92015 be billed together?
Yes. Refraction is not part of 92004 and is reported separately with 92015. Medicare does not cover it, so the patient or a vision plan usually pays, and many vision plans include it in the exam payment.
Is a patient referred from optometry to ophthalmology in the same group new?
Under Medicare, optometry and ophthalmology are separate specialties, so the patient can be new to the ophthalmologist. Some commercial plans treat them as one specialty, and many practices code these visits as established.
Sources
AAO EyeNet Savvy Coder fact sheet for the comprehensive eye visit codes; AOA billing and coding guidance on dilation; Medicare NCCI Policy Manual, Chapter 11, 2026; Medicare Claims Processing Manual, Chapter 12, section 30.6.7; CMS Recovery Audit issue 0039 on new patient ophthalmology codes; Medicare Benefit Policy Manual, Chapter 16, section 90; Ophthalmology Management coding columns on new patients and refraction; Review of Optometry coding column; Optometry and Ophthalmology Coding Alert on intermediate and comprehensive exams; CMS CY 2026 Physician Fee Schedule final rule fact sheet; AOA statement on the 2026 fee schedule; Medicare.gov coverage pages for glaucoma tests and diabetic eye exams; Blue Cross Blue Shield of Rhode Island ophthalmology exam policy; Review of Ophthalmology 2026 coding update.
Notes and disclosures
CPT is a registered trademark of the American Medical Association. Descriptions here are Vision Rescue summaries, not official CPT descriptors. This page is general information for eye care professionals and billing staff, not legal, billing or coding advice. Payer rules vary; verify codes, modifiers and coverage with the current official code sets, your Medicare contractor and the patient's plan. Questions: providers@visionrescue.com or 1-855-692-8024.
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