Essential Medical Eye Care
Essential Medical Eye Care provides supplemental medical eye care coverage. The patient’s medical insurance plan should be billed as the primary payer when you are contracted with the medical insurance plan’s network. Please refer to coordination of benefits in this section for more information.
Essential Medical Eye Care covers detection, treatment, and management of ocular and/or systemic conditions that produce ocular or visual symptoms.
Symptoms & Conditions
Examples of conditions that may be covered under the Essential Medical Eye Care include, but aren’t limited to:
|
Conditions: |
|
|---|---|
|
|
|
|
|
|
|
|
The Essential Medical Eye Care Core Benefits List describes all services covered under the Essential Medical Eye Care plan. Covered services are subject to change at VSP's discretion. Some services are limited to certain conditions/diagnosis codes and have frequency limitations. The established frequencies should accommodate the required quality care needs of most patients.
Exclusions
The following services are not covered under Essential Medical Eye Care:
- General anesthesia surgical procedures.
- Preoperative and postoperative surgical procedures, cataract extractions, or retinal surgery.
- Refractive surgery. Services provided for refractive diagnoses may be covered under your patient’s routine benefit.
- Prescription medication or supplies of any type.
- Eyeglasses or contact lenses.
Copays
Copays, if required, apply to medical eye exams only (92002-92014, 99202-99205, 99211-99215, 99421-99423, 99441-99443). Copays do not apply to non-exam services (e.g., diagnostic testing including fundus photography and optical coherence tomography).
Eligibility & Authorization
Check the VSP Patient Record Report to confirm Essential Medical Eye Care coverage. Patients choosing non-covered medical services should be informed of any out-of-pocket cost and asked to sign the Patient Responsibility Statement prior to receiving services. You can find the form under the Forms section of the Administration menu on VSPOnline on eyefinity.com.
Coding and Billing Documentation Standards
Providers are responsible for accurate documentation and claim submission of services performed. Claims should be coded appropriately according to industry standard coding guidelines including, but not limited to American Medical Association (AMA), Centers for Medicare and Medicaid Services (CMS), Current Procedural Terminology (CPT®), Healthcare Common Procedure Coding System (HCPCS), International Classification of Diseases (ICD-10 CM), and National Correct Coding Initiative (NCCI).
Claim submissions are subject to review including but not limited to, terms of benefit coverage, provider contract language, scope of licensure, coding policies, clinical payment guidelines, and coding software logic. All information required to support the services and medical necessity submitted on the claim is expected to be in the patient’s medical record and be available for review. VSP audits patient medical records according to the Clinical Practice Guidelines of the American Optometric Association (AOA) and the Preferred Practice Pattern® Guidelines of the American Academy of Ophthalmology (AAO).
Reminders:
- Essential Medical Eye Care services must be submitted on a separate authorization from routine vision claims.
- Report only those services appropriate for your licensure and your state’s current regulations.
- Code to the highest degree of specificity when indicating diagnosis.
- Standard timely filing guidelines apply.
Note:
VSP recognizes but does not currently support Place of Service (POS) code 02 for reporting telehealth services rendered from a distant site except when submitted on paper as a secondary for coordination of benefits. Additionally, VSP recognizes but does not currently support POS code 10 for reporting telehealth services provided in patient’s home.
Modifiers GQ or 95 are used to identify telemedicine services, as appropriate. Modifiers are used for information purposes only.
For information about the Interpretation and Report requirement for medical procedures, refer to Guidelines for the Interpretation and Report of Diagnostic Procedures.
Reimbursement
Essential Medical Eye Care Reimbursement
- Medical eye exams (CPT codes 920XX and 99202-99215) are reimbursed according to VSP Signature Plan payables, as reported on your practice’s Assigned Fee Report.
- To access the Assigned Fee Report for your practice, visit VSPOnline at eyefinity.com and click the View Fees link under Practice/Doctor Updates in the Administration area.
- Additional covered services are reimbursed at 80% of your usual and customary (U&C) fee, up to the Essential Medical Eye Care maximum allowable.
- VSP’s non-exam Essential Medical Eye Care services approximate the Centers for Medicare and Medicaid Services (CMS) Medicare Physician Fee Schedule amounts.
Medicaid Essential Medical Eye Care Reimbursement
- Reimbursement for approved Medicaid procedures will be 80% of your U&C fee or your state's VSP Medicaid fee schedule, whichever is lower.
-
VSP’s non-exam Essential Medical Eye Care services approximate your state’s Medicaid fee schedule amounts.
Pricing Rules for Surgical Procedures (see Surgical Services section below)
- When two or more covered surgical procedures are performed during the same operative session, multiple surgery reductions apply.
- 100% of the allowance for the most expensive surgical procedure or 80% of the billed; whichever is less.
- 50% of the allowance for the remaining surgical procedures or 80% of the billed; whichever is less.
Exam and Office Visit Frequency
Only one exam or office visit is payable per date of service, including any combination of VSP plans or benefits. Reimbursements aren’t available when multiple exams or office visits are submitted for the same dates of service, including the following in any combination:
- Intermediate or comprehensive routine exam
- Ophthalmological exam for medical related eye care
- Evaluation and management office visit
- Exam or evaluation and management service performed via telemedicine
Coordination of Benefits
Coordination of benefits (COB) applies to the payment of medical eye care benefits when a member is covered under two or more benefit plans. If a member has medical benefits under a medical health insurance plan that you’re contracted with, that plan is primary and VSP is secondary. In the event VSP is the secondary payer, VSP may be billed for the member’s out-of-pocket expenses. Examples are copayments, deductibles, charges for noncovered services, or charges for services not covered in full by the primary carrier. Providers are responsible for verifying coverage, as well as billing the other carrier(s).
See Coordination of Benefits section for more information about how to coordinate benefits.
Referrals
If your patient needs more treatment than you’re licensed for, or if your patient needs treatment for services not covered under Essential Medical Eye Care, refer the patient to their primary care physician or a specialist in their medical insurance plan’s network.
When making referrals, use the following guidelines and those listed under Patient Referrals in Levels of Service section of Eye Exams:
- Follow all referral protocols set by your patient’s health plan. Typically, an HMO requires that patient referrals be coordinated by the primary care physician (PCP). However, a PPO allows patients to receive care from any medical provider without a PCP referral.
- Provide your findings, in writing, to the doctor you’re referring the patient to.
- Forward your diagnostic findings, treatment plan, and follow-up results to your patient’s primary care physician. To help you coordinate care for patients with diabetes, we provide the optional Primary Care Physician Communication Form, available in the Forms section of the Administration menu on VSPOnline at eyefinity.com and in eClaim. This easy-to-use form is a convenient way to help manage eye health for patients with diabetes and underscores the importance of regular eye exams.
Instructions for the administration of specific-client plans are outlined in Client Details. Please check client details before providing services to covered patients.
Covered Services:
Exams and Office Visits
Comprehensive eye exams are covered once per 12-month period. Additional comprehensive eye exams are reimbursed at the intermediate level.
|
Code |
Description |
|---|---|
|
92002 |
Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; intermediate, new patient |
|
92004 |
Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; comprehensive, new patient, 1 or more visits |
|
92012 |
Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established patient |
|
92014 |
Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive, established patient, 1 or more visits. |
Evaluation and Management Services
Modifier 95 or GQ is used to designate telemedicine for eligible E/M services (99202 - 99215)
|
Code |
Description |
|---|---|
|
99202 |
Office or other outpatient for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 15 minutes must be met or exceeded. |
|
99203 |
Office or other outpatient for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded. |
|
99204 |
Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 45 minutes must be met or exceeded. |
|
99205 |
Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 60 minutes must be met or exceeded. |
|
99211 |
Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional. |
|
99212 |
Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 10 minutes must be met or exceeded. |
|
99213 |
Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 20 minutes must be met or exceeded. |
|
99214 |
Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded. |
|
99215 |
Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded. |
|
99242 |
Office or other outpatient consultation for a new or established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 20 minutes must be met or exceeded. |
|
99243 |
Office or other outpatient consultation for a new or established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded. |
|
99244 |
Office or other outpatient consultation for a new or established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded. |
|
99245 |
Office or other outpatient consultation for a new or established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 55 minutes must be met or exceeded. |
For additional information on billing evaluation and management services, please use the following AMA resource guides:
CPT® Evaluation and Management (E/M) Code and Guideline Changes
CPT® Evaluation and Management (E/M) Office Revisions Level of Medical Decision Making (MDM)
Special Ophthalmological Services
|
Code |
Description |
|---|---|
|
76510 |
Ophthalmic ultrasound, diagnostic; B-scan and quantitative A-scan performed during the same patient encounter Provide location modifier RT or LT. |
|
76511 |
Ophthalmic ultrasound, diagnostic; quantitative A-scan only Provide location modifier RT or LT. |
|
76512 |
Ophthalmic ultrasound, diagnostic; B-scan (with or without superimposed non-quantitative A-scan) Provide location modifier RT or LT. |
|
76513 |
Ophthalmic ultrasound, diagnostic; anterior segment ultrasound, immersion (water bath) B-scan or high resolution biomicroscopy, unilateral or bilateralProvide location modifier RT or LT. |
|
76514 |
Corneal pachymetry Allowable once per lifetime per patient. Allowable twice per lifetime with the following diagnoses: Z98.83 Filtering (vitreous) bleb after glaucoma surgery status Allowable once per 12-month period for the following diagnoses: H18.611- H18.613 Keratoconus, stable H18.621 – H18.623 Keratoconus, unstable |
|
76516 |
Ophthalmic biometry by ultrasound echography, A-scan |
|
76519 |
Ophthalmic biometry by ultrasound echography, A-scan, with intraocular lens power calculation Provide location modifier RT or LT. |
|
76529 |
Ophthalmic ultrasonic foreign body localization Provide location modifier RT or LT. |
|
92020 |
Gonioscopy (separate procedure) Allowable once per 12-month period when visual necessity is established. Allowable twice per 12-month period for patients with the following diagnoses: E08.311 - E13.3599 Diabetes mellitus with diabetic retinopathy H40.001 - H40.063 Glaucoma Suspect H40.10X0 - H40.1194 Primary open-angle glaucoma H40.20X0 - H40.243 Primary Angle-closure Glaucoma H40.61X0 - H40.63X4 Glaucoma Secondary to Drugs Q15.0 Congenital Glaucoma |
|
92025 |
Computerized corneal topography with interpretation and report Allowable once per 12-month period for the following diagnoses: H11.001 - H11.063 Pterygium H52.211 - H52.213 Irregular astigmatism Allowable twice per 12-month period for the following diagnoses: H16.001 - H16.073 Corneal ulcer H18.11 - H18.13 Bullous keratopathy H18.20 Unspecified corneal edema H18.221 - H18.223 Other corneal edema H18.831 - H18.833 Recurrent erosion of cornea Z94.7 Corneal transplant status |
|
92060 |
Sensorimotor examination with multiple measurements of ocular deviation (e.g., restrictive or paretic muscle with diplopia) with interpretation and report (separate procedure) |
|
92071 |
Fitting of contact lens for treatment of ocular surface disease Allowable diagnosis codes: H16.101 - H16.103 Unspecified superficial keratitis H16.141 - H16.143 Punctate keratitis H16.9 Unspecified keratitis H18.11 - H18.13 Bullous keratopathy H18.511 - H18.519 Endothelial corneal dystrophy H18.541 - H18.549 Lattice corneal dystrophy H18.591 - H18.599 Other hereditary corneal dystrophies H18.831 - H18.833 Recurrent erosion cornea H18.821 - H18.823 Corneal disorder due to contact lens H18.451 - H18.453 Nodular corneal degeneration S05.00XA - S05.02XS Injury of conjunctiva and corneal abrasion without foreign body T15.00XA - T15.02XS Foreign body in cornea T85.318A - T85.318S Breakdown (mechanical) of other ocular prosthetic devices, implants and grafts T85.328A - T85.328S Displacement of other ocular prosthetic devices, implants and grafts T85.398A - T85.398S Other mechanical complication of other ocular prosthetic devices, implants and grafts T86.8401 – T86.8409 Corneal transplant rejection T86.8411 – T86.8419 Corneal transplant failure Z94.7 Corneal transplant status Provide location modifier RT or LT. |
|
99070 |
Supplies are materials (except spectacles). Use for bandage contact lens only. Bill with 92071 only. Provide location modifier RT or LT. |
|
92081-92083 |
Visual field exam, unilateral or bilateral, with interpretation and report
Bill with an appropriate medical diagnosis code. |
|
92100 |
Serial tonometry with multiple measurements of intraocular pressure over an extended interval of time with interpretation and report, same day. See Special Handling Procedures for more information. |
|
92132 |
Scanning computerized ophthalmic diagnostic imaging, anterior segment, with interpretation and report, bilateral Allowable up to two times per 12-month period for the following diagnoses: H17.01 - H17.03 Adherent leukoma H17.11 - H17.13 Central corneal opacity H17.811 - H17.813 Minor opacity of cornea H17.821 - H17.823 Peripheral opacity of cornea H17.89 Other corneal scars and opacities H17.9 Unspecified corneal scar and opacity H18.11 - H18.13 Bullous keratopathy H18.20 Unspecified corneal edema H18.211 - H18.213 Corneal edema secondary to contact lens H18.221 - H18.223 Idiopathic corneal edema H18.231 - H18.233 Secondary corneal edema H21.89 Other specified disorders of iris and ciliary body H22 Disorders of iris and ciliary body in diseases classified elsewhere H40.1210 - H40.1294 Low-tension glaucoma H40.1310 - H40.1394 Pigmentary glaucoma H40.1410 - H40.1494 Capsular glaucoma with pseudoexfoliation of lens H40.20X0 - H40.20X4 Unspecified primary angle-closure glaucoma H40.211 - H40.213 Acute angle-closure glaucoma H40.2210 - H40.2294 Chronic angle-closure glaucoma H40.231 - H40.233 Intermittent angle-closure glaucoma H40.241 - H40.243 Residual stage of angle-closure glaucoma H40.30X0 - H40.33X4 Glaucoma secondary to eye trauma H40.40X0 - H40.43X4 Glaucoma secondary to eye inflammation H40.50X0 - H40.53X4 Glaucoma secondary to other eye disorders H40.60X0 - H40.63X4 Glaucoma secondary to drugs H40.811 - H40.813 Glaucoma with increased episcleral venous pressure H40.821 - H40.823 Hypersecretion glaucoma H40.831 - H40.833 Aqueous misdirection H40.89 Other specified glaucoma H42 Glaucoma in diseases classified elsewhere |
|
92133 |
Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, bilateral; optic nerve Allowable once per 12-month period for the following diagnoses: E08.311 Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy with macular edema E08.319 Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy without macular edema E08.3211 – E08.3399 Diabetes mellitus due to underlying condition with diabetic retinopathy E09.3211 – E09.3399 Drug or chemical induced diabetes mellitus with diabetic retinopathy E10.311 Type 1 diabetes mellitus with unspecified diabetic retinopathy with macular edema E10.319 Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema E10.3211 - E10.3219 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema E10.3291 - E10.3299 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema E10.3311 - E10.3319 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema E10.3391 - E10.3399 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema E11.311 Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema E11.319 Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema E11.3211 - E11.3219 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema E11.3291 - E11.3299 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema E11.3311 - E11.3319 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema E11.3391 - E11.3399 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema E13.311 Other specified diabetes mellitus with unspecified diabetic retinopathy with macular edema E13.319 Other specified diabetes mellitus with unspecified diabetic retinopathy without macular edema E13.3211 - E13.3219 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema E13.3291 - E13.3299 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema E13.3311 - E13.3319 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema E13.3391 - E13.3399 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema H31.101 - H31.103 Choroidal degeneration H31.111 - H31.113 Age-related choroidal atrophy H31.121 - H31.123 Diffuse secondary atrophy of choroid H33.331 - H33.333 Multiple defects of retina without detachment H35.00 Unspecified background retinopathy H35.40 - H35.469 Peripheral retinal degeneration H35.50 Unspecified hereditary retinal dystrophy H35.51 Vitreoretinal dystrophy H35.52 Pigmentary retinal dystrophy H35.53 Other dystrophies primarily involving the sensory retina H35.54 Dystrophies primarily involving the retinal pigment epithelium H35.361 - H35.363 Drusen (degenerative) of macula H36 Retinal disorders in diseases classified elsewhere H46.01 - H46.03 Optic papillitis H46.11 - H46.13 Retrobulbar neuritis H46.2 Nutritional optic neuropathy H46.3 Toxic optic neuropathy H46.8 Other optic neuritis H46.9 Unspecified optic neuritis H47.011 - H47.013 Ischemic optic neuropathy H47.021 - H47.023 Hemorrhage in optic nerve sheath H47.031 - H47.033 Optic nerve hypoplasia H47.091 - H47.093 Other disorders of optic nerve, not elsewhere classified H47.10 - H47.13 Papilledema H47.141 - H47.143 Foster-Kennedy syndrome H47.20 - H47.299 Optic atrophy H47.311 - H47.313 Coloboma of optic disc H47.321 - H47.323 Drusen of optic disc H47.331 - H47.333 Pseudopapilledema of optic disc H47.391 - H47.393 Other disorders of optic disc H47.41 - H47.49 Disorders of optic chiasm H47.511 - H47.539 Disorders of visual pathways H47.611 - H47.619 Cortical blindness H47.621 - H47.649 Disorders of visual cortex H47.9 Unspecified disorder of visual pathways H53.40 - H53.489 Visual field defects Q15.0 Congenital glaucoma Allowable twice per 12-month period for the following diagnoses: D31.30 Benign neoplasm of unspecified choroid E08.3411 - E08.3599 Diabetes mellitus due to underlying condition with diabetic retinopathy E09.3411 - E09.3599 Drug or chemical induced diabetes mellitus with diabetic retinopathy E10.3411 - E10.3419 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema E10.3491 - E10.3499 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema E10.3511 - E10.3519 Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema E10.3521 - E10.3529 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula E10.3531 - E10.3539 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula E10.3541 - E10.3549 Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment E10.3551 - E10.3559 Type 1 diabetes mellitus with stable proliferative diabetic retinopathy E10.3591 - E10.3599 Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema E11.3411 - E11.3419 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema E11.3491 - E11.3499 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema E11.3511 - E11.3519 Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, unspecified eye E11.3521 - E11.3529 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula E11.3531 - E11.3539 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula E11.3541 - E11.3549 Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment E11.3551 - E11.3559 Type 2 diabetes mellitus with stable proliferative diabetic retinopathy E11.3591 - E11.3599 Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema E13.3411 - E13.3419 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema E13.3491 - E13.3499 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema E13.3511 - E13.3519 Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema E13.3521 - E13.3529 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula E13.3531 - E13.3539 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula E13.3541 - E13.3549 Other specified diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment E13.3551 - E13.3559 Other specified diabetes mellitus with stable proliferative diabetic retinopathy E13.3591 - E13.3599 Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema H33.001 - H33.059 Retinal detachment with retinal break H33.101 - H33.103 Unspecified retinoschisis H33.111 - H33.113 Cyst of ora serrate H33.191 - H33.193 Other retinoschisis and retinal cysts H33.21 - H33.23 Serous retinal detachment H33.301 - H33.303 Unspecified retinal break H33.311 - H33.313 Horseshoe tear of retina without detachment H33.321 - H33.323 Round hole H33.41 - H33.43 Traction detachment of retina H33.8 Other retinal detachments H34.00 - H34.9 Retinal vascular occlusion H35.011 - H35.079 Background retinopathy and retinal vascular changes H35.171 - H35.173 Retrolental fibroplasia H35.21 - H35.22 Other non-diabetic proliferative retinopathy H35.30 - H35.389 Degeneration of macula and posterior pole H35.61 - H35.63 Retinal hemorrhage H35.70 - H35.739 Separation of retinal layers H35.81 Retinal edema H35.82 Retinal ischemia H35.89 Other specified retinal disorders H35.9 Unspecified retinal disorder H40.001 - H40.9 Glaucoma H42 Glaucoma in diseases classified elsewhere H44.21 - H44.23 Degenerative myopia H44.2A - H44.2A9 Degenerative myopia with choroidal neovascularization H44.2B - H44.2B9 Degenerative myopia with macular hole H44.2C - H44.2C9 Degenerative myopia with retinal detachment H44.2D - H44.2D9 Degenerative myopia with foveoschisis H44.2E - H44.2E9 Degenerative myopia with other maculopathy Q14.2 Congenital malformation of optic disc Q14.3 Congenital malformation of choroid Q14.8 Other congenital malformations of posterior segment of eye Q15.0 Congenital glaucoma S05.10XA - S05.12XS Contusion of eyeball and orbital tissues Cannot be billed with extended ophthalmoscopy (initial or subsequent) or fundus photography (including retinal screening). |
|
92134 |
Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, bilateral; retina Allowable once per 12-month period for the following diagnoses: E08.311 Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy with macular edema E08.319 Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy without macular edema E08.3211 – E08.3399 Diabetes mellitus due to underlying condition with diabetic retinopathy E09.3211 – E09.3399 Drug or chemical induced diabetes mellitus with diabetic retinopathy E10.311 Type 1 diabetes mellitus with unspecified diabetic retinopathy with macular edema E10.319 Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema E10.3211 - E10.3219 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema E10.3291 - E10.3299 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema E10.3311 - E10.3319 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema E10.3391 - E10.3399 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema E11.311 Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema E11.319 Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema E11.3211 - E11.3219 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema E11.3291 - E11.3299 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema E11.3311 - E11.3319 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema E11.3391 - E11.3399 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema E13.311 Other specified diabetes mellitus with unspecified diabetic retinopathy with macular edema E13.319 Other specified diabetes mellitus with unspecified diabetic retinopathy without macular edema E13.3211 - E13.3219 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema E13.3291 - E13.3299 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema E13.3311 - E13.3319 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema E13.3391 - E13.3399 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema H31.101 - H31.103 Choroidal degeneration H31.111 - H31.113 Age-related choroidal atrophy H31.121 - H31.123 Diffuse secondary atrophy of choroid H33.331 - H33.333 Multiple defects of retina without detachment H35.00 Unspecified background retinopathy H35.40 - H35.469 Peripheral retinal degeneration H35.50 Unspecified hereditary retinal dystrophy H35.51 Vitreoretinal dystrophy H35.52 Pigmentary retinal dystrophy H35.53 Other dystrophies primarily involving the sensory retina H35.54 Dystrophies primarily involving the retinal pigment epithelium H35.361 - H35.363 Drusen (degenerative) of macula H36 Retinal disorders in diseases classified elsewhere H46.01 - H46.03 Optic papillitis H46.11 - H46.13 Retrobulbar neuritis H46.2 Nutritional optic neuropathy H46.3 Toxic optic neuropathy H46.8 Other optic neuritis H46.9 Unspecified optic neuritis H47.011 - H47.013 Ischemic optic neuropathy H47.021 - H47.023 Hemorrhage in optic nerve sheath H47.031 - H47.033 Optic nerve hypoplasia H47.091 - H47.093 Other disorders of optic nerve, not elsewhere classified H47.10 - H47.13 Papilledema H47.141 - H47.143 Foster-Kennedy syndrome H47.20 - H47.299 Optic atrophy H47.311 - H47.313 Coloboma of optic disc H47.321 - H47.323 Drusen of optic disc H47.331 - H47.333 Pseudopapilledema of optic disc H47.391 - H47.393 Other disorders of optic disc H47.41 - H47.49 Disorders of optic chiasm H47.511 - H47.539 Disorders of visual pathways H47.611 - H47.619 Cortical blindness H47.621 - H47.649 Disorders of visual cortex H47.9 Unspecified disorder of visual pathways H53.40 - H53.489 Visual field defects L93.0 Discoid lupus erythematosus L93.2 Other local lupus erythematosus M05.40 or M05.49 Rheumatoid myopathy with rheumatoid arthritis M05.50 or M05.59 Rheumatoid polyneuropathy with rheumatoid arthritis M05.70 or M05.79 Rheumatoid arthritis with rheumatoid factor M05.80 or M05.89 Other rheumatoid arthritis with rheumatoid factor M05.9 Rheumatoid arthritis with rheumatoid factor, unspecified M06.00 or M06.09 Rheumatoid arthritis without rheumatoid factor M06.80 or M06.89 Other specified rheumatoid arthritis M06.9 Rheumatoid arthritis, unspecified Q15.0 Congenital glaucoma T37.2X1A - T37.2X4S Poisoning by antimalarials and drugs Z09 Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm Z79.84 Long term (current) use of oral hypoglycemic drugs Allowable twice per 12-month period for the following diagnoses: D31.30 Benign neoplasm of unspecified choroid E08.3411 - E08.3599 Diabetes mellitus due to underlying condition with diabetic retinopathy E09.3411 - E09.3599 Drug or chemical induced diabetes mellitus with diabetic retinopathy E10.3411 - E10.3419 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema E10.3491 - E10.3499 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema E10.3511 - E10.3519 Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema E10.3521 - E10.3529 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula E10.3531 - E10.3539 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula E10.3541 - E10.3549 Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment E10.3551 - E10.3559 Type 1 diabetes mellitus with stable proliferative diabetic retinopathy E10.3591 - E10.3599 Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema E11.3411 - E11.3419 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema E11.3491 - E11.3499 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema E11.3511 - E11.3519 Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, unspecified eye E11.3521 - E11.3529 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula E11.3531 - E11.3539 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula E11.3541 - E11.3549 Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment E11.3551 - E11.3559 Type 2 diabetes mellitus with stable proliferative diabetic retinopathy E11.3591 - E11.3599 Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema E13.3411 - E13.3419 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema E13.3491 - E13.3499 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema E13.3511 - E13.3519 Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema E13.3521 - E13.3529 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula E13.3531 - E13.3539 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula E13.3541 - E13.3549 Other specified diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment E13.3551 - E13.3559 Other specified diabetes mellitus with stable proliferative diabetic retinopathy E13.3591 - E13.3599 Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema H33.001 - H33.059 Retinal detachment with retinal break H33.101 - H33.103 Unspecified retinoschisis H33.111 - H33.113 Cyst of ora serrate H33.191 - H33.193 Other retinoschisis and retinal cysts H33.21 - H33.23 Serous retinal detachment H33.301 - H33.303 Unspecified retinal break H33.311 - H33.313 Horseshoe tear of retina without detachment H33.321 - H33.323 Round hole H33.41 - H33.43 Traction detachment of retina H33.8 Other retinal detachments H34.00 - H34.9 Retinal vascular occlusion H35.011 - H35.079 Background retinopathy and retinal vascular changes H35.171 - H35.173 Retrolental fibroplasia H35.21 - H35.23 Other non-diabetic proliferative retinopathy H35.30 - H35.389 Degeneration of macula and posterior pole H35.61 - H35.63 Retinal hemorrhage H35.70 - H35.739 Separation of retinal layers H35.81 Retinal edema H35.82 Retinal ischemia H35.89 Other specified retinal disorders H35.9 Unspecified retinal disorder H40.001 - H40.9 Glaucoma H42 Glaucoma in diseases classified elsewhere H44.21 - H44.23 Degenerative myopia H44.2A - H44.2A9 Degenerative myopia with choroidal neovascularization H44.2B - H44.2B9 Degenerative myopia with macular hole H44.2C - H44.2C9 Degenerative myopia with retinal detachment H44.2D - H44.2D9 Degenerative myopia with foveoschisis H44.2E - H44.2E9 Degenerative myopia with other maculopathy Q14.2 Congenital malformation of optic disc Q14.3 Congenital malformation of choroid Q14.8 Other congenital malformations of posterior segment of eye Q15.0 Congenital glaucoma S05.10XA - S05.12XS Contusion of eyeball and orbital tissues Cannot be billed with extended ophthalmoscopy (initial or subsequent) or fundus photography (including retinal screening). |
|
92136 |
Ophthalmic biometry by partial coherence interferometry with intraocular lens power calculation |
|
92201
92202 |
Ophthalmoscopy, extended; with retinal drawing and scleral depression of peripheral retinal disease (e.g., for retinal tear, retinal detachment, retinal tumor) with interpretation and report, unilateral or bilateral • Allowable once per 12-month period for the below diagnoses. Ophthalmoscopy, extended, with drawing of optic nerve or macula (e.g., for glaucoma, macular pathology, tumor) with interpretation and report, unilateral or bilateral Allowable once per 12-month period for the following diagnoses: A39.82 Meningococcal retrobulbar neuritis A51.43 Secondary syphilitic oculopathy A52.19 Other symptomatic neurosyphilis B39.4 - B39.9 Histoplasmosis B58.01 Toxoplasma chorioretinitis C69.00 - C69.92 Malignant neoplasm of eye and adnexa D09.21 - D09.22 Carcinoma in situ D31.21 - D31.22 Benign neoplasm of retina D31.31 - D31.32 Benign neoplasm of choroid E08.311 - E08.3599 Diabetes mellitus due to underlying condition with diabetic retinopathy E09.311 - E09.3599 Drug or chemical induced diabetes mellitus with diabetic retinopathy E10.311 - E10.3599 Type 1 diabetes mellitus with diabetic retinopathy E10.36 Type 1 diabetes mellitus with diabetic cataract E10.39 Type 1 diabetes mellitus with other diabetic ophthalmic complication E10.65 Type 1 diabetes mellitus with hyperglycemia E11.311 - E11.3599 Type 2 diabetes mellitus with diabetic retinopathy E11.36 Type 2 diabetes mellitus with diabetic cataract E11.39 Type 2 diabetes mellitus with other diabetic ophthalmic complication E11.65 Type 2 diabetes mellitus with hyperglycemia E13.311 - E13.3599 Other specified diabetes mellitus with diabetic retinopathy E13.36 Other specified diabetes mellitus with diabetic cataract E13.39 Other specified diabetes mellitus with other diabetic ophthalmic complication H05.30 - H05.359 Deformity of the orbit H05.401 - H05.429 Enophthalmos H05.50 - H05.53 Retained (old) foreign body following penetrating wound H05.89 Other disorders of orbit H15.811 - H15.9 Other disorders of sclera H16.241 - H16.243 Ophthalmia nodosa H20.00 - H20.9 Iridocyclitis H21.00 - H21.9 Degeneration of iris and ciliary body H21.331 - H21.333 Parasitic cyst of iris, ciliary body or anterior chamber H22 Disorders of iris and ciliary body in diseases classified elsewhere H30.001 - H30.93 Chorioretinal inflammations H31.101 - H31.129 Choroidal degeneration H33.001 - H33.8 Retinal detachments and breaks H34.00 - H34.9 Retinal vascular occlusion H35.00 - H36 Other retinal disorders H40.001 - H40.9 Glaucoma H42 Glaucoma in diseases classified elsewhere H43.00 - H43.9 Disorders of vitreous body H44.001 - H44.029 Purulent endophthalmitis H44.111 - H44.9 Disorders of the globe H46.00 - H46.9 Optic neuritis H47.011 - H47.099 Disorders of optic nerve, not elsewhere classified H47.10 - H47.149 Papilledema H47.20 - H47.299 Optic atrophy H47.311 - H47.399 Other disorders of optic disc H47.41 - H47.49 Disorders of optic chiasm M05.40 Rheumatoid myopathy with rheumatoid arthritis of unspecified site M05.49 Rheumatoid myopathy with rheumatoid arthritis of multiple sites M05.50 Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified site M05.59 Rheumatoid polyneuropathy with rheumatoid arthritis of multiple sites M05.70 Rheumatoid arthritis with rheumatoid factor of unspecified site without organ or systems involvement M05.79 Rheumatoid arthritis with rheumatoid factor of multiple sites without organ or systems involvement M05.80 Other rheumatoid arthritis with rheumatoid factor of unspecified site M05.89 Other rheumatoid arthritis with rheumatoid factor of multiple sites M05.9 Rheumatoid arthritis with rheumatoid factor, unspecified M06.00 Rheumatoid arthritis without rheumatoid factor, unspecified site M06.09 Rheumatoid arthritis without rheumatoid factor, multiple sites M06.80 Other specified rheumatoid arthritis, unspecified site M06.89 Other specified rheumatoid arthritis, multiple sites M06.9 Rheumatoid arthritis, unspecified M08.00 Unspecified juvenile rheumatoid arthritis of unspecified site M08.09 Unspecified juvenile rheumatoid arthritis, multiple sites M08.20 Juvenile rheumatoid arthritis with systemic onset, unspecified site M08.29 Juvenile rheumatoid arthritis with systemic onset, multiple sites M08.3 Juvenile rheumatoid polyarthritis (seronegative) M08.40 Pauciarticular juvenile rheumatoid arthritis, unspecified site M08.89 Other juvenile arthritis, multiple sites M35.2 Behcet's disease Q14.0 - Q14.9 Congenital malformation Q15.0 Congenital glaucoma Q85.00 - Q85.02 Neurofibromatosis S05.10XA - S05.12XS Contusion of eye and adnexa S05.50XA - S05.52XS Penetrating wound with foreign body S05.60XA - S05.62XS Penetrating wound without foreign body S05.8X1A - S05.92XS Other injuries of eye and orbit Do not report 92201, 92202 in conjunction with 92250 (fundus photography) |
|
92227 |
Imaging of retina for detection or monitoring of disease; with remote clinical staff review and report, unilateral or bilateral Allowable once per 12-month period. Do not report 92227 in conjunction with 92002-92014, 92133, 92134, 92250, 92228 or with the evaluation and management of the single organ system, the eye, 99202-99350. |
|
92228 |
Imaging of retina for detection or monitoring of disease; with remote physician or other qualified health care professional interpretation and report, unilateral or bilateral Do not report 92228 in conjunction with 92002-92014, 92133, 92134, 92250, 92227 or with the evaluation and management of the single organ system, the eye, 99202-99350. |
|
92250 |
Fundus photography with interpretation and report Allowable once per 12-month period. Allowable twice per 12-month period for the following diagnoses: E08.311 - E08.3599 Diabetes mellitus due to underlying condition with diabetic retinopathy E09.311 - E09.3599 Drug or chemical induced diabetes mellitus with diabetic retinopathy E10.311 - E10.3599 Type 1 diabetes mellitus with diabetic retinopathy E11.311 - E11.3599 Type 2 diabetes mellitus with diabetic retinopathy E13.311 - E13.3599 Other specified diabetes mellitus with diabetic retinopathy H30.001 - H30.93 Chorioretinal inflammations H31.001 - H31.9 Other disorders of the choroid H32 Chorioretinal disorders in diseases classified elsewhere H33.001 - H33.8 Retinal detachments and breaks H34.00 - H34.9 Retinal vascular occlusion H35.00 - H36 Other retinal disorders Cannot be billed with extended ophthalmoscopy (initial or subsequent) or scanning computerized ophthalmic diagnostic imaging (of optic nerve or retina). |
|
92250/52 |
Diabetic retinal screening (baseline imaging to confirm the absence of diabetic eye disease) Allowable once per 12-month period for Signature, Choice, and Advantage Plan patients who have diabetes without diabetic eye disease. Use CPT code 92250 with modifier 52 Bill diagnosis code Z13.5 in the primary position and diagnosis code E10.9, E11.9 or E13.9 in the secondary position. Z13.5 Encounter for screening for eye and ear disorders E10.9 - Type 1 diabetes mellitus without complications E11.9 - Type 2 diabetes mellitus without complications E13.9 - Other specified diabetes mellitus without complications Diabetic retinal screening is reimbursed $39 (or your U&C fee when less than $39). Medicaid members are not eligible for diabetic retinal screening. Medicaid covers fundus photography with interpretation and report with medical necessity. Cannot be billed with extended ophthalmoscopy (initial or subsequent) or scanning computerized ophthalmic diagnostic imaging (of optic nerve or retina). |
|
92260 |
Ophthalmodynamometry Service Allowance: Allowable once per 12-month period |
|
92270 |
Electro-oculography with interpretation and report Service Allowance: Allowable once per 12-month period. |
|
92273 |
Electroretinography (ERG), with interpretation and report; full field (i.e., ffERG, flash ERG, Ganzfeld ERG) Allowable once per 12-month period, as medically necessary. Provide location modifier RT or LT. |
|
92274 |
Electroretinography (ERG), with interpretation and report; multifocal (mfERG) Allowable once per 12-month period, as medically necessary. Provide location modifier RT or LT. |
|
92283 |
Color vision exam, extended Service Allowance: Allowable once per 12-month period as medically necessary. |
|
92284 |
Dark adaptation exam with interpretation and report Service Allowance: Allowable once per 12-month period. |
|
92285 |
External ocular photography with interpretation and report for documentation medical progress. Not allowed for pre-cataract diagnoses. Provide location modifier RT or LT. |
|
92286 |
Anterior segment imaging with interpretation and report; with specular microscopy and endothelial cell analysis Only covered for the following diagnoses: H18.11 - H18.13 Bullous keratopathy H18.51 Fuch’s Dystrophy H18.511 - H18.519 Endothelial corneal dystrophy Provide location modifier RT or LT. |
|
92287 |
Anterior segment imaging with interpretation and report; with fluorescein angiography Provide location modifier RT or LT. |
|
92499 |
Exam with refraction for diabetic patients only who experience vision shifts of ± 1.00 diopters or greater in at least one eye due to diabetes medications (must be documented in the patient’s file). Cannot be billed with another exam service on the same day. Refraction not reimbursed separately; payment is bundled with exam. If applicable, bill the diagnosis code with the correct eye location: left, right or bilateral. Allowable once per 12-month period for the following diagnoses: E10.311 Type 1 diabetes mellitus with unspecified diabetic retinopathy with macular edema E10.319 Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema E10.3211 - E10.3219 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema E10.3291 - E10.3299 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema E10.3311 - E10.3319 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema E10.3391 - E10.3399 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema E10.3411 - E10.3419 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema E10.3491 - E10.3499 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema E10.3511 - E10.3519 Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema E10.3521 - E10.3529 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula E10.3531 - E10.3539 Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula E10.3541 - E10.3549 Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment E10.3551 - E10.3559 Type 1 diabetes mellitus with stable proliferative diabetic retinopathy E10.3591 - E10.3599 Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema E11.311 Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema E11.319 Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema E11.3211 - E11.3219 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema E11.3291 - E11.3299 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema E11.3311 - E11.3319 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema E11.3391 - E11.3399 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema E11.3411 - E11.3419 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema E11.3491 - E11.3499 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema E11.3511 - E11.3519 Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, unspecified eye E11.3521 - E11.3529 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula E11.3531 - E11.3539 Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula E11.3541 - E11.3549 Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment E11.3551 - E11.3559 Type 2 diabetes mellitus with stable proliferative diabetic retinopathy E11.3591 - E11.3599 Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edemaE13.311 Other specified diabetes mellitus with unspecified diabetic retinopathy with macular edema E13.319 Other specified diabetes mellitus with unspecified diabetic retinopathy without macular edema E13.3211 - E13.3219 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema E13.3291 - E13.3299 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema E13.3311 - E13.3319 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema E13.3391 - E13.3399 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema E13.3411 - E13.3419 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema E13.3491 - E13.3499 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema E13.3511 - E13.3519 Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema E13.3521 - E13.3529 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula E13.3531 - E13.3539 Other specified diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula E13.3541 - E13.3549 Other specified diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment E13.3551 - E13.3559 Other specified diabetes mellitus with stable proliferative diabetic retinopathy E13.3591 - E13.3599 Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema Rubeosis iridis H21.1X1 Other vascular disorders of iris and ciliary body (rubeosis iridis), right eye H21.1X2 Other vascular disorders of iris and ciliary body (rubeosis iridis), left eye H21.1X3 Other vascular disorders of iris and ciliary body (rubeosis iridis), bilateral |
|
95930 |
Visual evoked potential (VEP) checkerboard or flash testing, central nervous system except glaucoma, with interpretation and report. Service Allowance: Allowable once per 12-month period. VSP will not reimburse fundus photography, extended ophthalmoscopy (initial or subsequent) or scanning computerized ophthalmic diagnostic imaging (of optic nerve or retina) on the same day as VEP testing. |
Surgical Services
Multiple surgical procedure payment reduction rules apply to the following:
|
Code |
Description |
|---|---|
|
65205 |
Removal of foreign body, external eye; conjunctival superficial Provide location modifier RT or LT. |
|
65210 |
Removal of foreign body, external eye; conjunctival embedded, subconjunctival or scleral nonperforating Provide location modifier RT or LT. |
|
65220 |
Removal of foreign body, external eye; corneal, without slit lamp Provide location modifier RT or LT. |
|
65222 |
Removal of foreign body, external eye; corneal, with slit lamp Provide location modifier RT or LT. |
|
65430 |
Scraping of cornea, diagnostic, for smear and/or culture Provide location modifier RT or LT. |
|
65435 |
Removal of corneal epithelium; with or without chemocauterization (abrasion, curettage) Provide location modifier RT or LT. |
|
67820 |
Correction of trichiasis; epilation, by forceps only Provide location modifier E1, E2, E3 or E4. |
|
67938 |
Removal of embedded foreign body, eyelid Provide location modifier RT or LT. |
|
68020 |
Incision of conjunctiva, drainage of cyst Provide location modifier E1, E2, E3 or E4. |
|
68040 |
Expression of conjunctival follicles (eg, for trachoma) Provide location modifier E1, E2, E3 or E4 |
|
68761 |
Closure of lacrimal punctum; by plug, each Allowable diagnosis codes:
H04.11 - H04.9 Disorders of lacrimal system H16.141 - H16.143 Punctate keratitis H16.221 - H16.223, H11.821 – H11.823, H04.829 Keratoconjunctivitis sicca, not specified as Sjogren's M35.00 – M35.03 Sjogren syndrome Temporary plugs are limited to one, per eyelid, in a 24-month period. Maximum of four (4) per lifetime. Permanent plugs are limited to one, per eyelid, in a 24-month period. Two additional plugs may be authorized if medically necessary; however, VSP will not reimburse more than two plugs per eyelid. Maximum of six (6) per lifetime. Bill the appropriate modifiers E1 (upper lid, left); E2 (lower lid, left); E3 (upper lid, right); or E4 (lower lid, right). Use modifier SC to report temporary plugs. Reimbursement Standard rules for coding a minor surgical procedure apply. Punctal occlusion by plug carries a 10-day global period. All services necessary to complete the procedure, are included in the payment for the procedure. Reimbursement for a minor surgical procedure includes the preoperative visit on the day of surgery, postoperative visits related to recovery, and supplies. Exam services (920XX or 992XX) and local anesthesia is also included in the procedure and should not be reported separately. Punctal occlusion is a unilateral procedure and reimbursement is per punctum. When two puncta are occluded at the same session, multiple surgery rules apply. Use modifier 51 (multiple procedures) when more than one punctum is occluded during the same session |
|
68801 |
Dilation of lacrimal punctum, with or without irrigation Provide location modifier RT or LT. |
|
68810 |
Probing of nasolacrimal duct, with or without irrigation Provide location modifier RT or LT. |
|
68815 |
Probing of nasolacrimal duct, with or without irrigation; with insertion of tube or stent Provide location modifier RT or LT. |
Pathology and Laboratory
|
Code |
Description |
|---|---|
|
83516 |
Immunoassay for analyte other than infectious agent antibody or infectious agent antigen; qualitative or semiquantitative, multiple step method If applicable, bill the diagnosis code with the correct eye location: left, right or bilateral. Allowable diagnosis codes include, but are not limited to, the following: H00.021 - H00.029 Hordeolum internum H01.011 - H01.019 Ulcerative blepharitis H01.01A - Ulcerative blepharitis right eye, upper and lower eyelids H01.01B - Ulcerative blepharitis left eye, upper and lower eyelids H02.031 - H02.039 Senile entropion H02.101 - H02.109 Unspecified ectropion H04.121 - H04.129 Dry eye syndrome H04.211 - H04.229 Epiphora H04.421 - H04.429 Chronic lacrimal canaliculitis H04.521 - H04.529 Eversion H04.561 - H04.569 Stenosis H10.521 - H10.539 Blepharoconjunctivitis H16.121 - H16.123 Filamentary keratitis H16.221 - H16.223 Keratoconjunctivitis sicca, not specified as Sjogren's H18.831 - H18.833 Recurrent erosion of cornea H40.10X0 - H40.1194 Primary open-angle glaucoma M35.00 - M35.03 Sjogren syndrome Use modifier QW - Clinical Laboratory Improvement Amendment (CLIA) waived test. Provide location modifier RT and/or LT. When billing for both eyes, code 83516 twice, on two lines, for 1-unit of service each, as follows: 83516-QW-RT 83516-QW-LT |
|
83861 |
Microfluidic analysis utilizing an integrated collection and analysis device, tear osmolarity If applicable, bill the diagnosis code with the correct eye location: left, right or bilateral. Allowable diagnosis codes include, but are not limited to, the following: H00.021 - H00.029 Hordeolum internum H01.011 - H01.019 Ulcerative blepharitis H01.01A - Ulcerative blepharitis right eye, upper and lower eyelids H01.01B - Ulcerative blepharitis left eye, upper and lower eyelids H02.031 - H02.039 Senile entropion H02.101 - H02.109 Unspecified ectropion H04.121 - H04.129 Dry eye syndrome H04.211 - H04.229 Epiphora H04.421 - H04.429 Chronic lacrimal canaliculitis H04.521 - H04.529 Eversion H04.561 - H04.569 Stenosis H10.521 - H10.539 Blepharoconjunctivitis H16.121 - H16.123 Filamentary keratitis H16.221 - H16.223 Keratoconjunctivitis sicca, not specified as Sjogren's H18.831 - H18.833 Recurrent erosion of cornea H40.10X0 - H40.1194 Primary open-angle glaucoma M35.00 - M35.03 Sjogren syndrome Use modifier QW - Clinical Laboratory Improvement Amendment (CLIA) waived test. Provide location modifier RT and/or LT. When billing for both eyes, code 83861 twice, on two lines, for 1-unit of service each, as follows: 83861-QW-RT |
|
87809 |
Infectious agent antigen detection by immunoassay with direct optical observation; Adenovirus Allowable diagnosis codes: H10.011 - H10.029 Mucopurulent conjunctivitis H10.11 - H10.13 Acute atopic conjunctivitis H10.221 - H10.223 Pseudomembranous conjunctivitis H10.231 - H10.233 Serous conjunctivitis H10.31 - H10.33 Unspecified acute conjunctivitis H10.401 - H10.403 Unspecified chronic conjunctivitis H10.411 - H10.413 Chronic giant papillary conjunctivitis H10.421 - H10.423 Simple chronic conjunctivitis H10.431 - H10.433 Chronic follicular conjunctivitis H10.44 Vernal conjunctivitis H10.45 Other chronic allergic conjunctivitis H10.89 Other conjunctivitis H16.261 - H16.263 Vernal keratoconjunctivitis Use modifier QW - Clinical Laboratory Improvement Amendment (CLIA) waived test. Provide location modifier RT and/or LT. When billing for both eyes, code 87809 twice, on two lines, for 1-unit of service each, as follows: 87809-QW-RT |
Urgent/emergency Services
Services received from a VSP network provider when medical eye care services are required for urgent or emergency care. Urgent and/or emergency facility charges are not covered.
|
Code |
Description |
|---|---|
|
99050 |
Service(s) provided in the office at times other than regularly scheduled office hours, or day when the office is normally closed (e.g., holidays, Saturday or Sunday), in addition to basic service |
|
99051 |
Service(s) provided in the office during regularly scheduled evening, weekend or holiday office hours, in addition to basic service |
|
99058 |
Service(s) provided on an emergency basis in the office, which disrupts other scheduled office services in addition to basic service |
Online Digital Evaluation and Management Services
Use the following codes to indicate established patient, patient initiated, online digital evaluation. Limited to one online evaluation and management code per seven-day period, per chief complaint. Cannot lead to another medical visit in the next 24 hours.
|
Code |
Description |
|---|---|
|
99421 |
Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 5-10 minutes |
|
99422 |
Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 11-20 minutes |
|
99423 |
Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 21 or more minutes |
Telephone Evaluation and Management Services
Use the following codes to indicate established patient, patient initiated, telephone evaluation. Limited to one telephone evaluation and management code per seven-day period, per chief complaint. Cannot lead to another medical visit in the next 24 hours.
Do not report these services in conjunction with 99202-99205, 99212-99215, 99241-99245, or 99421-99423.
|
Code |
Description |
|---|---|
|
99441 |
Telephone evaluation and management service, for established patient, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes Do not report 99441 in conjunction with 99202-99205, 99212-99215, 99241-99245, or 99421-99423 |
|
99442 |
Telephone evaluation and management service, for an established patient, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 11-20 minutes Do not report 99442 in conjunction with 99202-99205, 99212-99215, 99241-99245, or 99421-99423 |
|
99443 |
Telephone evaluation and management service, for an established patient not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 21-30 minutes Do not report 99443 in conjunction with 99202-99205, 99212-99215, 99241-99245, or 99421-99423 |
Interprofessional Telephone/Internet/Electronic Health Record Consultations
Use the following codes to report your office’s consultation services only when requested by another physician. Allowable once per patient, per seven-day period. Service is not reported if the patient was seen by the consultant physician within the past 14 days.
|
Code |
Description |
|---|---|
|
99446 |
Interprofessional telephone/Internet/electronic health record assessment and management service provided by a consultative physician or other qualified health care professional, including a verbal and written report to the patient's treating/requesting physician or other qualified health care professional; 5-10 minutes of medical consultative discussion and review |
|
99447 |
Interprofessional telephone/Internet/electronic health record assessment and management service provided by a consultative physician or other qualified health care professional, including, including a verbal and written report to the patient's treating/requesting physician or other qualified health care professional; 11-20 minutes of medical consultative discussion and review |
|
99448 |
Interprofessional telephone/Internet/electronic health record assessment and management service provided by a consultative physician or other qualified health care professional, including a verbal and written report to the patient's treating/requesting physician or other qualified health care professional; 21-30 minutes of medical consultative discussion and review |
|
99449 |
Interprofessional telephone/Internet/electronic health record assessment and management service provided by a consultative physician or other qualified health care professional, including a verbal and written report to the patient's treating/requesting physician or other qualified health care professional; 31 minutes or more of medical consultative discussion and review |
|
99451 |
Interprofessional telephone/internet/electronic health record assessment and management service provided by a consultative physician or other qualified health care professional, including a written report to the patient’s treating/requesting physician or other qualified health-care professional, five or more minutes of medical consultative time. |
|
99452 |
Interprofessional telephone/internet/electronic health record referral service(s) provided by a treating/requesting physician or qualified health-care professional, 30 minutes. Reported by the physician who is treating the patient and requesting the non-face-to-face consult for medical advice or opinion (not for a transfer of care or a face-to-face consult). |
Special Handling Procedures
|
Procedure |
Special Handling Procedures |
|---|---|
|
92201-92202 |
Extended ophthalmoscopy is included in the global reimbursement for retinal surgery. Extended ophthalmoscopy (direct or binocular indirect) may not be billed separately during an exam except when all of the following conditions are met: patient’s presenting symptoms and/or diagnosis of retinal or vitreoretinal problems support the need for extended ophthalmoscopy. The medical record indicates that extended ophthalmoscopy was performed. Dilated retinal evaluation with direct or binocular indirect ophthalmoscopy does not constitute extended ophthalmoscopy unless additional procedures (e.g., contact lens or three mirror evaluations) were required. Additional procedures must be clearly indicated in the patient's chart. The medical record should contain a detailed drawing that describes the retina, including defects. The drawing does not have to accompany the claim but should be available for review upon request. |
|
92250 |
Fundus photography is a procedure in which bilateral photographs of the retina are obtained for diagnostic purposes. Coverage is provided when fundus photography is: Performed during initial glaucoma care, if: 1. intraocular pressures are clearly documented in the patient's medical record and are at or above 21 mm Hg; or 2. intraocular pressures are between 15 and 20 mm Hg and there is clear funduscopic evidence of glaucomatous optic nerve damage (such as abnormal cup size, thinning or notching of the disc rim, progressive change, disc hemorrhage or nerve fiber layer defects). In either instance, repeat studies by the same doctor are covered if submitted at greater than one-year intervals, unless there are other clinical indications to justify the study. Preglaucoma, borderline glaucoma and glaucoma are generally slow disease processes that can be followed by modalities other than fundus photography. Used in evaluating rapid, progressive diabetic retinopathy. In this instance, coverage is provided only when there is no prior retinal laser surgery and photography is not performed more than once every six months. Fundus photography is not covered if used to evaluate stable or minimal diabetic retinopathy. |
|
95930 |
Visual evoked potentials (VEPs) are appropriate for 1) detecting optic neuritis at an early, subclinical stage, and 2) evaluating the following diseases of the optic nerve: Ischemic optic neuropathy Pseudotumor cerebri Toxic amblyopias Nutritional amblyopias Neoplasms compressing the anterior visual pathways Optic nerve injury or atrophy Hysterical blindness (to rule out) The patient’s medical record must contain documentation that fully supports the visual necessity for VEPs, including, but not limited to, relevant medical history, physical examination and results of pertinent diagnostic tests or procedures. If your technician is certified, a VEP test may be performed under general supervision (the doctor is not immediately available). If your technician is not certified, a VEP test must be performed with direct supervision (doctor is immediately available). |