135k views
4 votes
The ophthalmologist performs a review of history, external exam, ophthalmoscopy, biomicroscopy and tonometry on an established patient with a new cataract. What CPT® code is reported for this procedure?

1 Answer

1 vote

Final Answer:

The appropriate CPT® code for the ophthalmologist's comprehensive evaluation of an established patient with a new cataract is 99214.

Step-by-step explanation:

CPT® code 99214 is assigned for an office or other outpatient evaluation and management (E/M) service for an established patient that requires a detailed history, a comprehensive examination, and moderate complexity medical decision-making. In the context of the ophthalmologist's assessment, the performance of a review of history, external exam, ophthalmoscopy, biomicroscopy, and tonometry on a patient with a new cataract aligns with the criteria for code 99214. This code reflects a higher level of complexity and effort on the part of the healthcare provider compared to lower-level E/M codes.

The comprehensive evaluation includes a thorough examination of the patient's history, an external examination of the eye, ophthalmoscopy to assess the internal structures of the eye, biomicroscopy for a detailed examination of the anterior segment, and tonometry to measure intraocular pressure. These elements collectively contribute to the overall complexity of the service provided by the ophthalmologist. CPT® code 99214 is appropriate in this case, accurately capturing the intensity and depth of the evaluation performed on an established patient with a new cataract.

User Amro Younes
by
7.8k points