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Official Description

Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive, established patient, 1 or more visits

© Copyright 2026 American Medical Association. All rights reserved.

Common Language Description

A comprehensive level of general ophthalmological services is provided to an established patient within the course of one or more visits, as indicated by CPT® Code 92014. This code encompasses a thorough medical examination and evaluation of the patient's visual system, which does not need to be completed in a single session. The comprehensive evaluation includes a detailed history or interval history, along with general medical observations that are crucial for understanding the patient's overall health and visual status. The examination involves an external ocular and adnexal assessment, which covers the eyelids, eyelashes, eyebrows, eye alignment and motility, conjunctiva, cornea, and iris. Additionally, the use of a slit lamp is integral to this evaluation, allowing for a more in-depth examination of the anterior segment of the eye. The assessment also includes testing the gross visual field or visual acuity of each eye, sensorimotor examination, and routine ophthalmoscopy to inspect the ocular media, retina, and optic nerve. Tonometry is performed on established patients, particularly for those with known conditions such as cataracts, to measure intraocular pressure. Other diagnostic techniques such as keratometry, retinoscopy, and biomicroscopy are utilized, especially in cases of acute or complicated conditions. To facilitate a comprehensive examination, mydriatic agents may be employed to dilate the pupils, enhancing the visualization of the ocular media and fundus. Cycloplegic agents are also used to temporarily paralyze the ciliary muscle, aiding in the assessment of accommodation. Following the diagnostic evaluation, the physician has the option to initiate a new diagnostic treatment program or continue an existing one, which may involve prescribing medications, arranging for additional special services, consultations, laboratory tests, or radiology services as necessary.

© Copyright 2026 Coding Ahead. All rights reserved.

1. Indications

The procedure associated with CPT® Code 92014 is indicated for established patients who require a comprehensive ophthalmological evaluation. This may include patients presenting with various symptoms or conditions that necessitate a thorough assessment of their visual system. The following are specific indications for performing this procedure:

  • Established Patient Status The patient must be an established patient, meaning they have received care from the physician or practice in the past.
  • Visual Symptoms Patients may present with visual disturbances, such as blurred vision, double vision, or changes in visual acuity.
  • Ocular Conditions The procedure is indicated for patients with known ocular conditions, such as cataracts, glaucoma, or diabetic retinopathy, requiring ongoing management.
  • Routine Eye Examination This code is also applicable for routine eye examinations to monitor the health of the visual system in established patients.

2. Procedure

The procedure for CPT® Code 92014 involves several detailed steps to ensure a comprehensive evaluation of the patient's visual system. Each step is crucial for obtaining a complete understanding of the patient's ocular health.

  • Step 1: Patient History The physician begins by taking a thorough history or interval history from the patient. This includes inquiries about current symptoms, previous ocular conditions, and any relevant medical history that may impact the visual system.
  • Step 2: General Medical Observations Following the history, the physician conducts general medical observations to assess the patient's overall health, which can influence ocular health.
  • Step 3: External Ocular and Adnexal Examination The physician performs an external examination of the eyelids, lashes, brows, and alignment of the eyes. This step assesses the integrity of the ocular surface and surrounding structures.
  • Step 4: Slit Lamp Examination A slit lamp is utilized to conduct a detailed examination of the anterior segment of the eye, allowing for the assessment of the cornea, iris, and lens.
  • Step 5: Visual Acuity Testing The physician tests the visual acuity of each eye, which is essential for determining the clarity of vision and identifying any refractive errors.
  • Step 6: Sensorimotor Examination This examination assesses the eye movements and coordination between the eyes, which is important for diagnosing conditions affecting binocular vision.
  • Step 7: Routine Ophthalmoscopy The physician performs routine ophthalmoscopy to examine the ocular media, retina, and optic nerve, which is critical for detecting any abnormalities.
  • Step 8: Tonometry In established patients, tonometry is performed to measure intraocular pressure, particularly for those with known conditions like cataracts.
  • Step 9: Additional Diagnostic Techniques The physician may employ keratometry, retinoscopy, and biomicroscopy as needed, especially in cases of acute or complicated conditions.
  • Step 10: Use of Mydriatic and Cycloplegic Agents Mydriatic agents may be administered to dilate the pupils, enhancing the examination of the ocular media. Cycloplegic agents may also be used to temporarily paralyze the ciliary muscle, aiding in the assessment of accommodation.
  • Step 11: Treatment Program Initiation or Continuation After completing the evaluation, the physician either initiates a new diagnostic treatment program or continues an established one, which may involve prescribing medications or arranging for additional services.

3. Post-Procedure

Post-procedure care following the comprehensive ophthalmological evaluation under CPT® Code 92014 may include monitoring the patient's response to any prescribed treatments or medications. The physician may provide instructions regarding follow-up visits, especially if new treatments have been initiated or if there are ongoing concerns that require further evaluation. Patients may also be advised on any necessary lifestyle modifications or precautions based on their ocular health status. Additionally, arrangements for further diagnostic tests, consultations, or referrals to specialists may be made as needed to ensure comprehensive care.

Short Descr COMPRE OPH EXAM EST PT 1/>
Medium Descr OPH SVCS MEDICAL XM&EVAL COMPRE EST PT 1/>VST
Long Descr Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive, established patient, 1 or more visits
Status Code Active Code
Global Days XXX - Global Concept Does Not Apply
PC/TC Indicator (26, TC) 0 - Physician Service Code
Multiple Procedures (51) 0 - No payment adjustment rules for multiple procedures apply.
Bilateral Surgery (50) 2 - 150% payment adjustment does NOT apply.
Physician Supervisions 09 - Concept does not apply.
Assistant Surgeon (80, 82) 0 - Payment restriction for assistants at surgery applies to this procedure...
Co-Surgeons (62) 0 - Co-surgeons not permitted for this procedure.
Team Surgery (66) 0 - Team surgeons not permitted for this procedure.
Diagnostic Imaging Family 99 - Concept Does Not Apply
APC Status Indicator Clinic or Emergency Department Visit
Type of Service (TOS) 1 - Medical Care
Berenson-Eggers TOS (BETOS) M5C - Specialist - ophthalmology
MUE 1
CCS Clinical Classification 220 - Ophthalmologic and otologic diagnosis and treatment
25 Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service: it may be necessary to indicate that on the day a procedure or service identified by a cpt code was performed, the patient's condition required a significant, separately identifiable e/m service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. a significant, separately identifiable e/m service is defined or substantiated by documentation that satisfies the relevant criteria for the respective e/m service to be reported (see evaluation and management services guidelines for instructions on determining level of e/m service). the e/m service may be prompted by the symptom or condition for which the procedure and/or service was provided. as such, different diagnoses are not required for reporting of the e/m services on the same date. this circumstance may be reported by adding modifier 25 to the appropriate level of e/m service. note: this modifier is not used to report an e/m service that resulted in a decision to perform surgery. see modifier 57 for significant, separately identifiable non-e/m services, see modifier 59.
24 Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period: the physician or other qualified health care professional may need to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) unrelated to the original procedure. this circumstance may be reported by adding modifier 24 to the appropriate level of e/m service.
57 Decision for surgery: an evaluation and management service that resulted in the initial decision to perform the surgery may be identified by adding modifier 57 to the appropriate level of e/m service.
GW Service not related to the hospice patient's terminal condition
GC This service has been performed in part by a resident under the direction of a teaching physician
AQ Physician providing a service in an unlisted health professional shortage area (hpsa)
AP Determination of refractive state was not performed in the course of diagnostic ophthalmological examination
Q6 Service furnished under a fee-for-time compensation arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area
CR Catastrophe/disaster related
GY Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit
GA Waiver of liability statement issued as required by payer policy, individual case
GV Attending physician not employed or paid under arrangement by the patient's hospice provider
CC Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed)
LT Left side (used to identify procedures performed on the left side of the body)
X2 Continuous/focused services: for reporting services by clinicians whose expertise is needed for the ongoing management of a chronic disease or a condition that needs to be managed and followed with no planned endpoint to the relationship; reporting clinician service examples include but are not limited to: a rheumatologist taking care of the patient's rheumatoid arthritis longitudinally but not providing general primary care services
95 Synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system: synchronous telemedicine service is defined as a real-time interaction between a physician or other qualified health care professional and a patient who is located at a distant site from the physician or other qualified health care professional. the totality of the communication of information exchanged between the physician or other qualified health care professional and the patient during the course of the synchronous telemedicine service must be of an amount and nature that would be sufficient to meet the key components and/or requirements of the same service when rendered via a face-to-face interaction. modifier 95 may only be appended to the services listed in appendix p. appendix p is the list of cpt codes for services that are typically performed face-to-face, but may be rendered via a real-time (synchronous) interactive audio and video telecommunications system.
Q5 Service furnished under a reciprocal billing arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area
CG Policy criteria applied
RT Right side (used to identify procedures performed on the right side of the body)
X1 Continuous/broad services: for reporting services by clinicians, who provide the principal care for a patient, with no planned endpoint of the relationship; services in this category represent comprehensive care, dealing with the entire scope of patient problems, either directly or in a care coordination role; reporting clinician service examples include, but are not limited to: primary care, and clinicians providing comprehensive care to patients in addition to specialty care
22 Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service.
26 Professional component: certain procedures are a combination of a physician or other qualified health care professional component and a technical component. when the physician or other qualified health care professional component is reported separately, the service may be identified by adding modifier 26 to the usual procedure number.
27 Multiple outpatient hospital e/m encounters on the same date: for hospital outpatient reporting purposes, utilization of hospital resources related to separate and distinct e/m encounters performed in multiple outpatient hospital settings on the same date may be reported by adding modifier 27 to each appropriate level outpatient and/or emergency department e/m code(s). this modifier provides a means of reporting circumstances involving evaluation and management services provided by physician(s) in more than one (multiple) outpatient hospital setting(s) (eg, hospital emergency department, clinic). note: this modifier is not to be used for physician reporting of multiple e/m services performed by the same physician on the same date. for physician reporting of all outpatient evaluation and management services provided by the same physician on the same date and performed in multiple outpatient setting(s) (eg, hospital emergency department, clinic), see evaluation and management, emergency department, or preventive medicine services codes.
32 Mandated services: services related to mandated consultation and/or related services (eg, third party payer, governmental, legislative or regulatory requirement) may be identified by adding modifier 32 to the basic procedure.
50 Bilateral procedure: unless otherwise identified in the listings, bilateral procedures that are performed at the same session, should be identified by adding modifier 50 to the appropriate 5 digit code. note: this modifier should not be appended to designated "add-on" codes (see appendix d).
51 Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d).
52 Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use).
53 Discontinued procedure: under certain circumstances, the physician or other qualified health care professional may elect to terminate a surgical or diagnostic procedure. due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. this circumstance may be reported by adding modifier 53 to the code reported by the individual for the discontinued procedure. note: this modifier is not used to report the elective cancellation of a procedure prior to the patient's anesthesia induction and/or surgical preparation in the operating suite. for outpatient hospital/ambulatory surgery center (asc) reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use).
58 Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78.
59 Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25.
76 Repeat procedure or service by same physician or other qualified health care professional: it may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 76 to the repeated procedure or service. note: this modifier should not be appended to an e/m service.
77 Repeat procedure by another physician or other qualified health care professional: it may be necessary to indicate that a basic procedure or service was repeated by another physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 77 to the repeated procedure or service. note: this modifier should not be appended to an e/m service.
78 Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.)
79 Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.)
93 Synchronous telemedicine service rendered via telephone or other real-time interactive audio-only telecommunications system : synchronous telemedicine service is defined as a real-time interaction between a physician or other qualified health care professional and a patient who is located away at a distant site from the physician or other qualified health care professional. the totality of the communication of information exchanged between the physician or other qualified health care professional and the patient during the course of the synchronous telemedicine service must be of an amount and nature that is sufficient to meet the key components and/or requirements of the same service when rendered via a face-to-face interaction.
A1 Dressing for one wound
AI Principal physician of record
AR Physician provider services in a physician scarcity area
AY Item or service furnished to an esrd patient that is not for the treatment of esrd
E1 Upper left, eyelid
E2 Lower left, eyelid
E3 Upper right, eyelid
E4 Lower right, eyelid
FS Split (or shared) evaluation and management visit
FT Unrelated evaluation and management (e/m) visit on the same day as another e/m visit or during a global procedure (preoperative, postoperative period, or on the same day as the procedure, as applicable). (report when an e/m visit is furnished within the global period but is unrelated, or when one or more additional e/m visits furnished on the same day are unrelated)
GB Claim being re-submitted for payment because it is no longer covered under a global payment demonstration
GT Via interactive audio and video telecommunication systems
GX Notice of liability issued, voluntary under payer policy
GZ Item or service expected to be denied as not reasonable and necessary
HC Adult program, geriatric
JZ Zero drug amount discarded/not administered to any patient
KW Dmepos item subject to dmepos competitive bidding program number 4
LL Lease/rental (use the 'll' modifier when dme equipment rental is to be applied against the purchase price)
P2 A patient with mild systemic disease
PD Diagnostic or related non diagnostic item or service provided in a wholly owned or operated entity to a patient who is admitted as an inpatient within 3 days
PO Excepted service provided at an off-campus, outpatient, provider-based department of a hospital
Q0 Investigational clinical service provided in a clinical research study that is in an approved clinical research study
Q1 Routine clinical service provided in a clinical research study that is in an approved clinical research study
Q3 Live kidney donor surgery and related services
QB Prescribed amounts of stationary oxygen for daytime use while at rest and nighttime use differ and the average of the two amounts exceeds 4 liters per minute (lpm) and portable oxygen is prescribed
QJ Services/items provided to a prisoner or patient in state or local custody, however the state or local government, as applicable, meets the requirements in 42 cfr 411.4 (b)
QW Clia waived test
SC Medically necessary service or supply
SU Procedure performed in physician's office (to denote use of facility and equipment)
TP Medical transport, unloaded vehicle
TW Back-up equipment
UD Medicaid level of care 13, as defined by each state
XE Separate encounter, a service that is distinct because it occurred during a separate encounter
XP Separate practitioner, a service that is distinct because it was performed by a different practitioner
XU Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service
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2024-01-01 Changed Short and Medium Descriptions changed.
2013-01-01 Changed Description Changed
2009-01-01 Changed Code description changed
Pre-1990 Added Code added.
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