Hello,
I am new to the ophthalmology specialty and am coding for opthalmology E/M services (92002-92004 and 92012-92014). I am having a difficult time recognizing what is an evaluation of the complete visual system. I have been reading the CPT book, but it doesn’t specify this. I have been googling and have come up with little on what it looks like in the documentation. Here is a sample below where the physician is billing for a 92014. I’m not sure if this even qualifies because there is really no history only the Active Problem List, and there is very brief documentation of the other elements of a comprehensive exam. Any help or guidance would be greatly appreciated. Thank you.

Problem List:
Patient Active Problem List
Diagnosis
• Spastic diplegic cerebral palsy
• Obstructive hydrocephalus
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Current Medications:
Current Medications

No current outpatient prescriptions on file.
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No current facility-administered medications for this visit.

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Allergies:
No Known Allergies
Vital Signs:
Vitals:
* 04/21/17 0917
BP: (!) 89/58
Pulse: 70
Temp: 99.1 °F (37.3 °C)
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Visual Acuity Screening
* Right eye Left eye Both eyes
Without correction: * * *
With correction: 20/70 20/200 20/70
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REASON FOR VISIT:
Chief Complaint
Patient presents with
• Follow-up
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ASSESSMENT OF VISION: as above= right eye better than left.
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MOTILITY EXAM: no strabismus is noted, good alignment.
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EXTERNAL EXAM: unremarkable. The bifocals are set far to low to be useful for this child.
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ANTERIOR SEGMENT EXAM: Normal lids, lashes, conjunctiva, cornea, lens, iris, A/C each eye.
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FUNDUS EXAM: flat macula each eye without pigmentary retinopathy or notable folds. I was not able to see the periphery but did not see any sign of ROP treatment with laser or cryo. Mom does not remember any. Moderate optic atrophy present ou.
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REFRACTION: over retinoscopy shows present correction to be appropriate (see the script). I gave a new script so the bifocals might be properly positioned.
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ASSESSMENT: former 26 weeker with history of IVH and shunt, and apparent optic atrophy. How much of his vision difficulty is retinal, and how much is optic nerve and central, I cannot say. He does not have high uncorrected refractive error.
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PLAN: Follow up in 3 months so I can evaluate vision in new glasses.
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REFERRALS:
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FOLLOW UP: 3 mos quick check
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