Billing code 92004: Comprehensive eye examMedicare rate & RVUs in Illinois
Comprehensive medical eye evaluation for a new patient, with examination of the visual system and initiation of a diagnostic or treatment plan.
Medicare pays $142.77–$153.46 for 92004 in the office in Illinois, from Rest Of Illinois to Suburban Chicago. Which amount applies depends on the service address.
Medicare allowed amount for participating (non-QP) physicians, before deductible, coinsurance and claim adjustments. Not a patient’s bill or a hospital charge.
On this page 9 sections
What 92004 covers
A comprehensive new-patient eye evaluation includes the patient's history, general medical observation, external and ophthalmoscopic examinations, gross visual fields, and a basic sensorimotor examination. Slit lamp examination, tonometry, and dilation may be performed when indicated. The ophthalmologist or optometrist initiates a diagnostic or treatment plan based on the findings. The service is commonly performed in an office but may also be performed in a facility.
Report 92004 when the patient meets the new-patient definition and the documented service meets the comprehensive examination requirements rather than those for an intermediate examination. A patient is new if no professional service was received from the physician or another physician of the same specialty in the same group during the preceding three years. The evaluation may take one or more visits; report the completed service once. Record the examination findings and plan, and support the medical necessity of the visit. Refraction, when performed, is separately reported. Medicare prices 92004 as bilateral, so modifier 50 does not increase payment.
This summary was written with AI assistance from CMS physician fee schedule data and checked against the CMS billing rules shown here. Rates on this page come directly from CMS files.
Where 92004 pays more and less in Illinois
The same RVUs, adjusted for each area’s costs. Open a locality for its calculation, history and nearby areas.
4 payment localities
$142.77 to $153.46
| Payment locality | Office | Facility |
|---|---|---|
| Chicago | $152.23 | $80.06 |
| East St. Louis | $143.99 | $77.92 |
| Rest Of Illinois | $142.77 | $77.21 |
| Suburban Chicago | $153.46 | $79.70 |
How the 92004 rate is calculated
Each of 92004’s three RVUs is multiplied by a geographic index (GPCI) for the payment locality, added up, and multiplied by the conversion factor. Drag the indexes or enter a ZIP to see what moves the rate.
How the rate is built · 92004
RVUs × geographic indexes × conversion factor
Swap in your local Medicare rate.
Work 1.82Practice expense 2.62Malpractice 0.04
All indexes start at 1.000 (the national rate). Enter a ZIP or drag a slider.
Payment rules and modifiers for 92004
The CMS indicators that decide how 92004 is paid alongside other services.
CMS payment indicators · 92004
Comprehensive eye exam
| Rule | CMS value | What it means |
|---|---|---|
| Global period | XXX | The global surgery concept doesn’t apply. |
| Multiple procedures | 0 | No multiple-procedure reduction. |
| Bilateral (modifier 50) | 2 | Already bilateral by definition: paid once at 100%. |
| Assistant at surgery (80/81/82/AS) | 0 | Not paid without supporting documentation. |
| Co-surgeons (62) | 0 | Not permitted. |
| Team surgery (66) | 0 | Not permitted. |
| Professional/technical | 0 | Physician service: no professional/technical split. |
92004 compared with similar codes
Compare codes
92004 vs 92014 vs 92002 vs 99204 vs 92018: national Medicare rates
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How to choose
- 92014Comprehensive eye exam
- Both represent comprehensive eye examinations. Use 92004 for a new patient and 92014 for an established patient under the three-year, same-specialty-and-group definition.
- 92002Eye examination
- 92002 is an intermediate new-patient examination. Choose 92004 when the documented examination meets the comprehensive requirements, including ophthalmoscopy and initiation of a diagnostic or treatment plan.
- 99204Office visit
- 99204 is a new-patient office E/M level selected by medical decision making or qualifying time. Select 92004 by the documented comprehensive ophthalmological service; do not report both codes for the same evaluation.
- 92018Eye examination
- 92018 describes a comprehensive eye examination performed under general anesthesia. Use 92004 for a qualifying comprehensive new-patient ophthalmological evaluation that is not an examination under general anesthesia.
92004 billing questions
When should 92004 be chosen over 92002?
Choose 92004 when the documented new-patient service meets the comprehensive examination requirements, including ophthalmoscopy and initiation of a diagnostic or treatment plan. Choose 92002 for an intermediate new-patient examination.
Is refraction included in 92004?
No. When performed and documented, determination of refractive state is reported separately with 92015. Medicare generally excludes refraction from coverage.
Should modifier 50 or RT/LT be appended?
Do not append modifier 50 to seek bilateral payment: 92004 is already priced as bilateral. An RT or LT modifier does not create a second payable eye examination.
Can 92004 and a new-patient E/M code be billed on the same day?
Do not report both for the same evaluation by the same provider. Select the code that describes the documented encounter; a genuinely separate E/M service requires its own supporting documentation and must meet applicable billing rules.
What if the comprehensive exam takes two visits?
The comprehensive service may span more than one visit, such as when a patient returns to complete the examination. Report 92004 once when the service is complete.
Are dilation and tonometry billed separately?
No. Dilation and tonometry performed as part of the comprehensive examination are not separately reported. A distinct diagnostic test, such as medically necessary visual field testing, may be reported separately when performed.
Where these rates come from
FeeBase calculates base physician payments from CMS work, practice-expense and malpractice RVUs, adjusted by each locality’s geographic indexes and the conversion factor. Services without a published rate are labeled, never given a made-up amount. Amounts are Medicare allowed amounts before claim adjustments: not a patient’s bill or a commercial rate.
CMS RVU26D · effective Oct 1, 2026 through the day before Jan 1, 2027
Show the CMS file lines behind this rate
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