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The CPT® Code 92018 refers to a comprehensive ophthalmological examination and evaluation conducted under general anesthesia. This procedure may involve manipulation of the globe to facilitate a thorough diagnostic examination. Prior to the administration of general anesthesia, mydriatic eye drops are utilized to dilate the pupils, allowing for a more detailed assessment of the eye's internal structures. An intravenous line is established to ensure the safe delivery of anesthesia. Once the pupils are sufficiently dilated, general anesthesia is administered, enabling the physician to perform a complete examination without patient discomfort. The examination encompasses the anterior segment of the eye, which includes critical structures such as the cornea, iris, and lens. Additionally, intraocular pressure is measured, and various eye measurements, including the length and width of the eye and corneal thickness, are taken. Refraction may also be performed to ascertain the appropriate eyeglass prescription. The posterior segment of the eye, which includes the retina, optic disc, and optic nerve, is thoroughly examined, and photographs may be captured as necessary to document any findings. It is important to note that CPT® Code 92018 is designated for a complete examination under anesthesia, while CPT® Code 92019 is used for a limited examination. Both codes can be reported for bilateral procedures, ensuring comprehensive documentation and billing for the services rendered.
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The procedure associated with CPT® Code 92018 is indicated for patients requiring a comprehensive ophthalmological examination under general anesthesia. This may be necessary in cases where the patient is unable to cooperate for a standard examination due to age, cognitive impairment, or other medical conditions. Specific indications include:
The procedure for CPT® Code 92018 involves several critical steps to ensure a thorough ophthalmological examination under general anesthesia. The steps are as follows:
After the completion of the examination under general anesthesia, patients are monitored as they recover from the effects of the anesthesia. Post-procedure care may include ensuring that the patient is stable and alert before discharge. Patients may experience temporary blurred vision due to the mydriatic drops used during the procedure, and they should be advised not to drive or operate heavy machinery until their vision returns to normal. Follow-up appointments may be scheduled to discuss the findings of the examination and any necessary treatment options based on the results. It is essential to provide patients with clear instructions regarding post-operative care and any signs or symptoms that should prompt immediate medical attention.
| Short Descr | COMPL OPH EXAM GENERAL ANES | Medium Descr | COMPL OPH XM&EVAL GENERAL ANES W/WO MNPJ GLOBE | Long Descr | Ophthalmological examination and evaluation, under general anesthesia, with or without manipulation of globe for passive range of motion or other manipulation to facilitate diagnostic examination; complete | 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) | 0 - 150% payment adjustment for bilateral procedures 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 | Hospital Part B services paid through a comprehensive APC | 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 |
| XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service | RT | Right side (used to identify procedures performed on the right side of the body) | 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. | 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. | 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). | 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. | 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. | 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.) | CR | Catastrophe/disaster related | GC | This service has been performed in part by a resident under the direction of a teaching physician | 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 | LT | Left side (used to identify procedures performed on the left side of the body) | SG | Ambulatory surgical center (asc) facility service | 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 | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure |
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| 2024-01-01 | Changed | Short and Medium Descriptions changed. |
| Pre-1990 | Added | Code added. |
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