All covered services must be rendered in a VSP qualified office location. VSP follows AMA guidelines for exam requirements, as outlined in CPT. Below, you’ll find guidelines, tests, and processes for each service level.

This level of service provides evaluation of the complete visual system with or without cycloplegia or mydriasis. A comprehensive level of service is considered to make up a single service. But you are not required to provide all of those services in one session. Where possible, record all tests with quantitative measurements.

Appropriate evaluation and recording of data in each area outlined below is required. See the Exam Documentation for these requirements.

Case History

• Your patient’s chief complaint or reason for an exam (note: the chief complaint should also be the primary diagnosis on the claim and should determine whether to bill VSP for a routine exam or bill for a medical exam)
• Ocular and visual health history (your patient’s and patient’s family, past and present)
• General health status (e.g., significant illnesses and medical conditions)
• Current medication and medication allergies
• Visual demands for work, school, and recreation

Neurological Integrity

• Pupillary reflexes
• Ocular motility/Versions (versions must be recorded separately from binocular function testing)

Refractive Status Evaluation

• Entering visual acuities (at 20 ft) with habitual Rx or unaided acuity, all recorded monocularly. Document monocular distance acuities for each eye for monovision contact lens patients.
•  Determination of refractive state with best corrected visual acuities (recorded monocularly). Testing may be delegated to qualified staff under the supervision of a licensed VSP Network Doctor (as permitted by state regulation and may be done with or without DPA's (diagnostic pharmaceutical agents)
• Accommodative function is based on the doctor's professional judgment and is not an exam requirement for all patients. Any near point accommodation testing should be performed when clinically indicated.

Diagnosis & Treatment Plan

We require diagnosis codes and/or related descriptions, plus documentation of the diagnosis in the exam chart notes. Z01.00 and Z01.01 are not acceptable as the sole diagnosis with a date of service on or after 10/1/15 and when there is another more appropriate refractive or medical diagnosis to use.

A diagnosis taken from an eClaim printout, CMS-1500 Form, VSP Savings Statement, or a superbill will not be acceptable unless signed or initialed by the doctor. Subjective Rx findings will not be accepted as a replacement for the written diagnosis.

Documentation of a treatment plan, by the doctor, is required in your patient’s chart notes.

Use this level of service when your patient will not benefit from all services included in a comprehensive exam. Evaluation and data recording in each area outlined below is required to qualify a service as intermediate.

Case History

• Your patient’s chief complaint or reason for an exam
• Ocular and visual health history (your patient’s and family, past and present)
• General health status (e.g., significant illnesses and medical conditions)
• Current medication and medication allergies
• Visual demands for work, school and recreation

Visual System Health Status Evaluation

• External exam
• Biomicroscopy (anterior segment photos are a separate procedure and are not acceptable as a replacement for biomicroscopy without separate documentation of anterior segment findings)
• Internal/Fundus exam including direct and/or indirect ophthalmoscopy, with or without dilation and, at a minimum, a numerical notation of cup-to-disc ratio documented for each eye*

Refractive Status Evaluation

• Determination of refractive state with best corrected visual acuities (recorded monocularly). Testing may be delegated to qualified staff under the supervision of a licensed VSP Network Doctor (as permitted by state regulation) and may be done with or without DPA's (diagnostic pharmaceutical agents)

Diagnosis & Treatment Plan

We require diagnosis codes and/or related descriptions, plus documentation of the diagnosis in the exam chart notes. Z01.00 and Z01.01 are not acceptable as the sole diagnosis with a date of service on or after 10/1/15 and when there is another more appropriate refractive or medical diagnosis to use.

A diagnosis taken from an eClaim printout, CMS-1500 Form, VSP Savings Statement, or a superbill will not be acceptable unless it is signed or initialed by the doctor. Subjective Rx findings will not be accepted as a replacement for the written diagnosis.

Documentation of a treatment plan, by the doctor, is required in your patient’s chart notes.

In some cases, you may need to refer your patient to another doctor, as appropriate under the circumstances. If you determine that your VSP patient needs care beyond your own scope of practice, please refer the patient to the appropriate doctor as follows:

• In case of a medical emergency, call the primary care doctor if required by your patient’s medical plan, or refer your patient to the appropriate doctor. If the primary doctor and/or the appropriate doctor is/are not available, please refer your patient to a hospital emergency room.
• Provide your findings in writing and 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 usually allows patients to receive care from any medical provider without a PCP referral.
• Keep a copy of the referral letter in your patient’s records

We will cover Evaluation and Management exams under the Essential Medical Eye Care. Refer to your Physician’s Current Procedural Terminology (CPT) codebook for explanation and a description of evaluation and management services.

The American Diabetes Association, American Optometric Association, and American Academy of Ophthalmology recommend that patients with diabetes receive an annual dilated eye exam. A dilated retinal eye exam is also a measure of clinical quality designated by the National Committee for Quality Assurance (NCQA).

In support of this standard of care, VSP highly recommends patients with diabetes receive a dilated retinal eye exam.

We recognize that at times there are good reasons for not providing a dilated exam. In those cases, medical record documentation of the rationale for not performing dilation is required. Examples include:

• Patient refused
• Dilated exam was performed within the last 12 months
• Patient scheduled dilation for a later date
• Patient is under the care of another practitioner
• Patient has a history of adverse or allergic reaction to mydriatic eye drops

Additionally, communicating exam findings to a patient’s primary care provider (PCP) is critical to ensuring continuity of care for patients with chronic and serious conditions. This communication also establishes you as an important part of the health care continuum and identifies your role in the care of patients with diabetes and other health conditions. To help you with this communication, we provide the optional Primary Care Provider Communication Form. You can find it in the Forms Library section of the Administration area on VSPOnline. If you prefer to use your own form, you are welcome to do so.

Please see our algorithm for Diabetes, for further reference.

The Healthcare Effectiveness Data and Information Set (HEDIS®) is one of healthcare’s most widely used performance improvement tools. The National Committee for Quality Assurance (NCQA) collects HEDIS data from health plans and other healthcare organizations to create annual health outcome surveys. Health plans use HEDIS data to measure performance and identify opportunities for improvement.

HEDIS includes more than 90 measures across multiple domains of care. These measures relate to public health issues, including (and not limited to) asthma medication use, blood pressure control, cancer screening, diabetes care, heart disease, and smoking and tobacco use cessation.

Eye Exam for Patients With Diabetes (EED) – Effectiveness of Care HEDIS Measure

Eye Exam for Patients With Diabetes (EED) is a specific HEDIS measure that requires health plans offering commercial, Medicaid, and Medicare plans to report the percentage of members with diabetes who had a dilated or retinal eye exam.

Measurement Definition:
Patients ages 18–75 with diabetes (Type 1 or Type 2) who received screening or monitoring for diabetic retinal eye disease:

• Retinal or dilated eye exam by an eye care professional in the measurement year or,
• A negative retinal or dilated eye exam by an eye care professional in the year prior to the measurement year.
• Note: Fundus photography with interpretation and report and certain types of retinal imaging (CPT^® codes 92227, 92228, 92250, 92260, and 92314) covered by Essential Medical Eye Care may also meet the performance measurement.

What are CPT Category II Codes?

• CPT Category II codes are tracking codes which facilitate data collection related to quality and performance measurement. They allow providers to report services based on nationally recognized, evidence-based performance guidelines for improving quality of patient care.
• CPT Category II codes describe clinical components, usually evaluation, management, or clinical services.
• Category II codes are not to be used as a substitute for Category I codes.
• CPT Category II codes are for r

What are CPT Category II Codes?

Current Procedural Terminology (CPT^®) Category II codes are informational, supplemental tracking codes that can be used for quality and performance measurement. These codes are intended to facilitate data collection about the quality of care for certain services (e.g., dilated or retinal eye exam) that support performance measures (e.g., Eye Exam for Patients With Diabetes (EED) HEDIS performance measure).

When VSP members with diabetes receive a dilated or retinal eye exam from a network doctor, in addition to billing the exam CPT code, VSP instructs doctors to bill the appropriate supplemental CPT Category II code, which can be used for HEDIS performance measurement.

Including HEDIS supplemental data on VSP claims strengthens the role doctors of optometry have in their patients' healthcare and highlights the impact they have on protecting their patients' vision and overall health. In addition, when VSP network doctors include CPT Category II codes on claims, this data can be securely delivered to VSP health plan clients, reducing the administrative burden of medical record chart reviews for doctors and their staff.

• Category II codes are not to be used as a substitute for Category I codes. CPT Category II codes are for reporting purposes only and are not separately reimbursable. Bill CPT Category II codes with a $0.00 charge amount.
• If you receive a claim denial, your reporting code will still be included in the quality measure.

When billing dilated or retinal eye exams for VSP patients with diabetes, include the appropriate supplemental CPT Category II code, for the Eye Exam for Patients With Diabetes (EED) - HEDIS performance measure: 

HEDIS^® is a registered trademark of the National Committee for Quality Assurance (NCQA).
Current Procedural Terminology (CPT) Category II codes developed by the American Medical Association (AMA).