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Essential Medical Eye Care
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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:

 
  • Age-related macular degeneration (AMD)
  • Glaucoma and cataracts
  • Conjunctivitis
  • Ocular discomfort and pain
  • Diabetic eye disease
  • Ocular surface disease
  • Foreign body and abrasions
  • Recent onset of flashes, floaters, and visual field loss

 

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:
H18.601- H18.603 Keratoconus, unspecified

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
H34.00 - H34.9 Retinal Vascular Occlusion

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
Q13.4 Congenital anomalies of corneal size and shape

Allowable twice per 12-month period for the following diagnoses:

H16.001 - H16.073 Corneal ulcer
H17.00 - H17.9 Corneal scars and opacities

H18.11 - H18.13 Bullous keratopathy

H18.20 Unspecified corneal edema

H18.221 - H18.223 Other corneal edema
H18.40 Corneal degeneration, unspecified
H18.451 - H18.453 Nodular degeneration of cornea
H18.461 - H18.463 Peripheral degenerations of cornea
H18.49 Other corneal degenerations
H18.501 - H18.599 Corneal dystrophies
H18.601 - H18.623 Keratoconus
H18.70 - H18.793 Other corneal deformities

H18.831 - H18.833 Recurrent erosion of cornea
T26.11XA - T26.12XS Burn of cornea and conjunctival sac
T26.61XA - T26.62XS Corrosion of cornea and conjunctival sac

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


Allowable twice per 12-month period when visual necessity is established.

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)

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
83861-QW-LT

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
87809-QW-LT

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 with Interpretation and Report

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
Visually evoked potential (VEP) checkerboard or flash testing, central nervous system except glaucoma, with interpretation and report

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).