Coding Ahead
CasePilot
Medical Coding Assistant
Case2Code
Search and Code Lookup Tool
RedactPHI
HIPAA-Compliant PHI Redaction
DetectICD10CM
ICD-10-CM Code Detection
Log in Register free account
1 code page views remaining. Guest accounts are limited to 1 page view. Register free account to get 5 more views.
Log in Register free account

Official Description

External ocular photography with interpretation and report for documentation of medical progress (eg, close-up photography, slit lamp photography, goniophotography, stereo-photography)

© Copyright 2025 American Medical Association. All rights reserved.

Common Language Description

External ocular photography is a specialized procedure utilized to capture detailed images of the external structures of the eye. This includes critical components such as the eyelids, eyelashes, sclerae, conjunctiva, and cornea. Additionally, it may encompass certain aspects of the anterior chamber, particularly the iris and filtration angle. The procedure employs various photographic techniques, including slit lamp photography, goniophotography, stereo-photography, and close-up photography, to ensure comprehensive documentation. The resulting images can be preserved in multiple formats, such as prints, slides, videotape, or digital media, facilitating easy access and review. Following the photography, a physician meticulously examines the captured images, providing an interpretation and report that details the findings. This analysis allows for a comparison with prior photographs, enabling the physician to track any changes over time, including the resolution of conditions, progression of injuries, or any late effects that may arise. This documentation is essential for monitoring the medical progress of patients and making informed clinical decisions.

© Copyright 2025 Coding Ahead. All rights reserved.

1. Indications

External ocular photography is indicated for various conditions and situations where detailed visual documentation of the eye's external structures is necessary. The following are specific indications for performing this procedure:

  • Monitoring of Eye Conditions External ocular photography is utilized to document and track the progression of ocular conditions affecting the external eye structures, allowing for ongoing assessment and management.
  • Injury Assessment This procedure is performed to capture the state of injuries to the eye, providing a visual record that can be referenced in future evaluations.
  • Pre- and Post-Operative Documentation It is used to document the condition of the eye before and after surgical interventions, aiding in the evaluation of surgical outcomes.
  • Comparison of Findings The procedure allows for the comparison of current findings with previous photographs, which is crucial for assessing changes over time.

2. Procedure

The procedure for external ocular photography involves several key steps to ensure accurate and effective documentation of the eye's external structures. The following outlines the procedural steps:

  • Preparation of the Patient The patient is positioned comfortably, and the area around the eyes is prepared to ensure clear visibility. This may involve the use of appropriate lighting and positioning to optimize the photographic outcome.
  • Selection of Photography Technique The physician selects the appropriate photographic technique based on the specific structures to be documented. Techniques may include slit lamp photography, which provides a magnified view of the eye, goniophotography for capturing the angle of the anterior chamber, stereo-photography for three-dimensional imaging, or close-up photography for detailed images of specific areas.
  • Image Capture The selected technique is employed to capture high-quality images of the external ocular structures. The physician may take multiple images from different angles to ensure comprehensive documentation.
  • Review and Interpretation After capturing the images, the physician reviews the photographs, interpreting the findings and noting any significant observations. This includes comparing the current images with previous ones to assess any changes in the condition.
  • Documentation and Reporting Finally, a detailed report is generated, summarizing the findings from the photographs. This report serves as a critical component of the patient's medical record and is used for ongoing management and treatment planning.

3. Post-Procedure

Post-procedure care for external ocular photography is generally minimal, as the procedure is non-invasive. Patients may be advised to avoid any irritants or allergens that could affect the eyes following the photography. The physician will review the findings with the patient, discussing any necessary follow-up appointments or additional treatments based on the documented images. It is important for patients to understand the significance of the photographs in monitoring their eye health and to maintain regular check-ups as recommended.

Short Descr EXTERNAL OCULAR PHOTOGRAPHY
Medium Descr XTRNL OCULAR PHOTOG W/I&R DOCMT MED PROGRESS
Long Descr External ocular photography with interpretation and report for documentation of medical progress (eg, close-up photography, slit lamp photography, goniophotography, stereo-photography)
Status Code Active Code
Global Days XXX - Global Concept Does Not Apply
PC/TC Indicator (26, TC) 1 - Diagnostic Tests for Radiology Services
Multiple Procedures (51) 7 - Special payment adjustment rules on the technical component (TC) of multiple diagnostic ophthalmology services 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 STV-Packaged Codes
Type of Service (TOS) Q - Vision Items or Services
Berenson-Eggers TOS (BETOS) M5C - Specialist - ophthalmology
MUE 1
CCS Clinical Classification 220 - Ophthalmologic and otologic diagnosis and treatment
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).
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.
TC Technical component; under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier 'tc' to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier tc; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles
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.
RT Right side (used to identify procedures performed on the right side of the body)
GC This service has been performed in part by a resident under the direction of a teaching physician
LT Left side (used to identify procedures performed on the left side of the body)
GW Service not related to the hospice patient's terminal condition
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).
AQ Physician providing a service in an unlisted health professional shortage area (hpsa)
XU Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service
GA Waiver of liability statement issued as required by payer policy, individual case
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
Q1 Routine clinical service provided in a clinical research study that is in an approved clinical research study
XS Separate structure, a service that is distinct because it was performed on a separate organ/structure
E1 Upper left, eyelid
E3 Upper right, eyelid
E4 Lower right, eyelid
CR Catastrophe/disaster related
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.
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.
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.
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.)
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.
CC Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed)
E2 Lower left, eyelid
GV Attending physician not employed or paid under arrangement by the patient's hospice provider
GZ Item or service expected to be denied as not reasonable and necessary
KX Requirements specified in the medical policy have been met
P2 A patient with mild systemic disease
Q0 Investigational clinical service provided in a clinical research study that is in an approved clinical research study
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
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
XE Separate encounter, a service that is distinct because it occurred during a separate encounter
Date
Action
Notes
2024-01-01 Changed Short and Medium Descriptions changed.
2013-01-01 Changed Medium Descriptor changed.
Pre-1990 Added Code added.
Code
Description
Code
Description
Code
Description
Code
Description
CasePilot

Get instant expert-level medical coding assistance.

Ask about:
CPT Codes Guidelines Modifiers Crosswalks NCCI Edits Compliance Medicare Coverage
Example: "What is CPT code 99213?" or "Guidelines for E/M services"