Do you understand when to use a 99213 vs a 92012?

This past week I was participating in a webinar on ocular surface disease. There was a component to the discussion on the prevalence of ocular surface disease and the financial impact that actively managing the disease has on a practice.

During the discussion, another presenter provided the financial impact using a model of billing 99213 codes for most follow ups. He then made the observation that you could increase the projections by using 92012 codes rather than 99213 codes but did not elaborate further (which is understandable since that was not the focus of the webinar). I thought that I would spend this week's EyeCodeBlog illustrating the differences between both codes.

The short take home message is this:

If you provide care that is individualized to the specific patient for a specific clinical condition (in this case ocular surface disease), and you satisfy both a 99213 AND a 92012, choose the code that reimburses the practice better (hint: it is nearly always the 92012)!

So, how do you know which you code you qualify for? The answers lie in the 97 documentation guidelines and CPT definitions for a 99213 and 92012. Let's cover each:

99213 (we only to score 2 of the following but at least 1 should be MDM)-

  • History: Expanded Problem Focused

  • History of Present Illness: 1-3 elements

  • Review of Systems: 1 element

  • Past Family and Social History: none

  • Examination: Expanded Problem Focused (6-8 elements)

  • LOW level of medical decision making, this would include 1 stable chronic problem (like dry eye)

92012 -

  • New diagnosis and or treatment problem

  • History

  • Orientation and Mood & Affect

  • Slit lamp and adnexal exam

  • Initiation of a diagnosis and/or treatment program

Clinical example where we could qualify for either level code:

A patient presents for a dry eye follow up with the following:


  • Location: OU

  • Severity: 6 (stable)

  • Duration: worse in the morning

  • Modifying Factors: Optive - no help

ROS: No medication allergies


  • Acuity: OD/OS: 20/20

  • Cornea OU: 1+ inferior staining

  • Conjunctiva OU: 1+ injection

  • Eyelids OU: 1+ telanjectasia, with frothing along margins

  • IOP: OD/OS: 18/18

  • A/C: deep and quiet


  1. Evaporative Dry Eye

  2. Meibomian gland dysfunction


  1. Refresh Optive Advance OU BID-QID

  2. Bruder Mask OU QD, Ocusoft Foam OU QD, 2000 mg PO QD Omega 3's, monitor in 1 month

Since in this example we would qualify for a 92012 (because there is a new treatment plan) and we would also qualify for a 99213 based on 97 documentation guidelines. In our practice, we would choose the 92012 because it typically reimburses us about $15-$20 more than the 99213.