In simple words: This is an eye exam for patients who haven't seen this eye doctor (or another eye doctor in the same practice) in the last three years. The doctor will look at the outside of your eyes, the inner structures, and may use eye drops to dilate your pupils. The exam helps diagnose and create a treatment plan for eye problems.

This code represents an intermediate level ophthalmological evaluation performed on a new patient. It includes a review of the patient's history, general medical observation, external ocular and adnexal examination, and other diagnostic procedures as needed, such as ophthalmoscopy with mydriasis.It also encompasses the initiation of a diagnostic and treatment program, which may involve prescribing medications, ordering additional tests, or scheduling consultations.

Example 1: A new patient presents with sudden blurred vision. The ophthalmologist conducts an intermediate eye exam (92002) to assess the condition, including a dilated eye exam and determines the cause to be a vitreous detachment. A treatment plan is initiated., A new patient has a family history of glaucoma and comes for an eye exam. The ophthalmologist performs an intermediate exam (92002) which includes tonometry and other tests to check for signs of the disease and establishes a baseline for future monitoring., A new patient experiences eye pain and redness. The ophthalmologist performs an intermediate eye exam (92002), including a slit-lamp examination, and diagnoses iritis.Treatment with eye drops is initiated.

Documentation should include the patient's history, chief complaint, findings from the external ocular and adnexal examination, any diagnostic tests performed (e.g., ophthalmoscopy, tonometry), the diagnosis, and the initiated treatment plan.