Refraction services billing
- Refraction code 92015 is not a covered benefit when billed with a medical diagnosis under all Priority Health plans, including Medicare and Medicaid.
- For routine vision exams, the refraction will be a covered service when billed with routine eye exam codes S0620 and S0621.
References for non-coverage of refraction services
See
Priority Health medical policy 91538,
Vision Care, which states that "refractive exams for assessment of visual acuity are not covered." This policy is consistent with that of other payers, including Medicare. Section 6.1.A.1(d) of the HMO Certificate of Coverage states, "one vision screening during each contract year to determine vision loss. Vision screenings do not include refractions, which are tests to determine eyeglass prescription."
Priority Health Medicare plans do not cover refractions because they are statutorily excluded from coverage by the Social Security Act (SSA) section 1862 (a)(7):
(a) Not withstanding any other provision of this title, no payment may be made under Part A or Part B for any expenses incurred for items or services–7) where such expenses are for routine physical checkups, eyeglasses (other than eyewear described in section 1861(s)(8)) or eye examinations for the purpose of prescribing, fitting, or changing eyeglasses, procedures performed (during the course of any eye examination) to determine the refractive state of the eyes, hearing aids or examinations therefore, or immunizations (except as otherwise allowed under section 1861(s)(10) and subparagraph (B), (F), (G), (H), or (K) of paragraph (1)).
