CPT® Code 92002

Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; intermediate, new patient

An intermediate level of general ophthalmological services is provided to a new patient under CPT® Code 92002. A new patient is defined as an individual who has not received any services from the same physician or from any other physicians of the same specialty within the same group practice for a period of three years. This code is utilized when the ophthalmologist evaluates either a new condition or an existing condition that has become complicated by a new diagnosis or management issue, which may not necessarily be related to the primary diagnosis. The intermediate evaluation encompasses a comprehensive approach that includes taking a detailed history and making general medical observations. The examination involves an external ocular and adnexal assessment, the use of a slit lamp for detailed examination, routine ophthalmoscopy, biomicroscopy, and tonometry, which are performed for conditions that do not necessitate comprehensive care. Additional techniques such as keratometry and retinoscopy are also employed. Mydriasis is utilized to facilitate routine ophthalmoscopy by dilating the pupils, thereby enhancing the visualization of the ocular media and fundus. Following the diagnostic evaluation, the physician is responsible for initiating a diagnostic treatment program, which may include prescribing necessary medications and arranging for any additional special services, consultations, laboratory tests, or radiology services as required for the patient's care.