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35.2.2 Vision Examinations
Medically necessary vision services for treatment purposes include, but are not limited to:
• Eye examinations that include refraction in order to diagnose refractive error, aphakia, diseases of the eye, or the need for eye surgery.
•One eye examination that includes refraction for the purposes of obtaining eyewear during a calendar year.
Note: Eye examinations for aphakia or disease or injury to the eye are not subject to any frequency limitations. More frequent refractive eye exams may be reimbursed if recommended by a school nurse, teacher, or parent, or if medically necessary.
Ophthalmologists and optometrists must submit vision exams with the following vision examination procedure codes:
Procedure codes 99201, 99202, 99203, 99204, and 99205, or procedure codes 99211, 99212, 99213, 99214, and 99215 are denied if submitted for reimbursement with the same date of service by the same provider as the procedure codes in the table above.
Procedure codes 92015, S0620, and S0621 are denied when submitted with the same date of service as procedure codes 92002, 92004, 92012, and 92014.
Procedure codes 92002 and 92004 are considered for reimbursement once every 2 years per client, per provider only.
Procedure 92020, 92060, and 92100 are denied if submitted with the same date of service as procedure code 92002, 92004, 92012, or 92015.
Procedure code 92065 is denied if submitted with the same date of service as the following procedure codes:
Procedure codes S0620 and S0621 are limited to once per calendar year for the purpose of obtaining eyewear and must be submitted with one of the following diagnosis codes:
Refractions performed for medical reasons (submitted for reimbursement using procedure codes 92002, 92004, 92012, 92014, and 92015) are not subject to the diagnosis limitations noted above.
Special services listed in the following table may be considered for reimbursement in addition to procedure codes 92002, 92004, 92012, 92014, and 92015:
Procedure codes 92018 and 92019 may be considered for reimbursement to ophthalmologists only.
Procedure code 92020 is denied as part of another service when submitted with the same date of service as procedure code 92018, 92019, or 92285.
Procedure codes 92019, 92020, and 92260 are denied as part of another service when submitted with the same date of service as procedure code 92018.
Procedure code 92140 is denied as part of another service when submitted with the same date of service as procedure code 92120.
Procedure code 92025 is denied as part of another service when submitted within the global surgical pre/post care days of an ophthalmological surgical procedure.
Procedure code 92025 is limited to once per day per client and must be submitted with one of the following diagnosis codes to be considered for reimbursement:
|
Diagnosis Code
|
Description
|
|
36720
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Unspecified astigmatism
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|
36722
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Irregular astigmatism
|
|
37000
|
Corneal ulcer, unspecified
|
|
37001
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Marginal corneal ulcer
|
|
37002
|
Ring corneal ulcer
|
|
37003
|
Central corneal ulcer
|
|
37004
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Hypopyon ulcer
|
|
37005
|
Mycotic corneal ulcer
|
|
37006
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Perforated corneal ulcer
|
|
37007
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Mooren's ulcer
|
|
37020
|
Unspecified superficial keratitis
|
|
37021
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Punctate keratitis
|
|
37022
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Macular keratitis
|
|
37023
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Filamentary keratitis
|
|
37024
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Photokeratitis
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37031
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Phlyctennular keratoconjunctivitis
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37032
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Limbar and corneal involvement in vernal conjunctivitis
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37033
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Keratoconjunctivitis sicca, not specified as Sjögren's
|
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37034
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Exposure keratoconjunctivitis
|
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37035
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Neurotrophic keratoconjunctivitis
|
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37040
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Unspecified keratoconjunctivitis
|
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37044
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Keratitis or keratoconjunctivitis in exanthema
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37049
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Other unspecified keratoconjunctivitis
|
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37050
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Unspecified interstitial keratitis
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37052
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Diffuse interstitial keratitis
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37054
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Sclerosing keratitis
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37055
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Corneal abscess
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37059
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Other interstitial and deep keratitis
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37060
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Unspecified corneal neovascularization
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37061
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Localized vascularization of cornea
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37062
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Pannus (corneal)
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37063
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Deep vascularization of cornea
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37064
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Ghost vessels (corneal) in corneal neovasculation
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3708
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Other forms of keratitis
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3709
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Unspecified keratitis
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37100
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Unspecified corneal opacity
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37101
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Minor opacity of cornea
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37102
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Peripheral opacity of cornea
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37103
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Central opacity of cornea
|
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37104
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Adherent leucoma
|
|
37120
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Unspecified corneal edema
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37121
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Idiopathic corneal edema
|
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37122
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Secondary corneal edema
|
|
37123
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Bullous keratopathy
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37140
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Unspecified corneal degeneration
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37142
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Recurrent erosion of cornea
|
|
37146
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Nodular degeneration of cornea
|
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37148
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Peripheral degenerations of cornea
|
|
37149
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Other corneal degenerations
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37150
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Unspecified corneal dystrophy
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37151
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Juvenile epithelial corneal dystrophy
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|
37152
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Other anterior corneal dystrophy
|
|
37153
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Granular corneal dystrophy
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37154
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Lattice corneal dystrophy
|
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37155
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Macular corneal dystrophy
|
|
37156
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Other stromal corneal dystrophies
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37157
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Endothelial corneal dystrophy
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37158
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Other posterior corneal dystrophies
|
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37160
|
Unspecified keratoconus
|
|
37161
|
Keratoconus, stable condition
|
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37162
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Keratoconus, acute hydrops
|
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37170
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Unspecified corneal deformity
|
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37171
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Corneal ectasia
|
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37172
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Descemetocele
|
|
37173
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Corneal staphyloma
|
|
37234
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Pingueculitis
|
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37240
|
Unspecified pterygium
|
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37241
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Peripheral pterygium, stationary
|
|
37242
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Peripheral pterygium, progressive
|
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37243
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Central pterygium
|
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37244
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Double pterygium
|
|
37245
|
Recurrent pterygium
|
|
37289
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Other disorders of conjunctiva
|
|
69513
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Stevens-Johnson syndrome
|
|
69514
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Stevens-Johnson syndrome - toxic epidermal necrolysis overlap syndrome
|
|
69515
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Toxic epidermal necrolysis
|
|
74341
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Congenital anomaly of corneal size and shape
|
|
8710
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Ocular laceration without prolapse of intraocular tissue
|
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8711
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Ocular laceration with prolapse or exposure of intraocular tissue
|
|
9402
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Alkaline chemical burn of cornea and conjunctival sac
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9403
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Acid chemical burn of cornea and conjunctival sac
|
|
9404
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Other burn of cornea and conjunctival sac
|
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99651
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Mechanical complication of other specified device, implant, and graft due to corneal graft
|
|
V425
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Cornea replaced by transplant
|
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V4561
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Cataract extraction status
|
|
V4569
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Other states following surgery of eye and adnexa
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Opticians, optometrists, and ophthalmologists may submit procedure codes 92326 and 95933 for miscellaneous ophthalmological services.
Ophthalmologists and Optometrists may submit the following procedure codes:
Procedure codes 99201, 99202, 99203, 99204, and 99205, or procedure codes 99211, 99212, 99213, 99214, and 99215 are denied if submitted for reimbursement with the same date of service by the same provider as the procedure codes in the table above.
Procedure code 92230 is denied when submitted with the same date of service by the same provider as 92235.
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