Optometrist scope of service
Applies to:
All plans
Medicare plans follow Medicare coverage and billing rules
Medical policy
Vision Care - 91538
Priority Health medical plans do not cover routine vision services, so we do not contract with optometrists to provide them.
Routine vision services billing through EyeMed
Priority Health partners with EyeMed Vision Care for administration of:
- Our PriorityVisionSM plan for commercial members
- The Enhanced Vision, Dental and Hearing plan for our Medicare Advantage plan members.
Routine vision services for all Priority Health commercial and Medicare products must be billed to EyeMed Vision Care. EyeMed administers all aspects of routine vision including claims, customer service and provider network.
Visit the EyeMed Vision Care website, portal.eyemedvisioncare.com, for more information.
Optometrist medical vision services billing
Priority Health reimburses optometrists for the following codes when medical necessity criteria are met. Fees are reimbursed at 85% of the regional professional fee schedule. See our standard fee schedules.
Key
- YES = Reimbursed
- -- = Not reimbursed
| Code | Description | Fully Funded | Self- Funded | Healthy Michigan Plan/ Medicaid |
Medicare |
|---|---|---|---|---|---|
| 65205 | Removal of foreign body | YES | YES | YES | YES |
| 65210 | Removal of foreign body, external eye; conjuctival embedded (includes concretions), subconjunctival, or scleral non-perforating | YES | YES | -- | YES |
| 65220 | Corneal, without slit lamp | YES | YES | YES | YES |
| 65222 | Corneal, with slit lamp | YES | YES | -- | YES |
| 65430 | Scraping of cornea, diagnostic, for smear | YES | YES | YES | YES |
| 65435 | Removal of corneal epithelium; with or without chemocauterization (abrasion, curettage) | YES | YES | YES | YES |
| 65436 | Removal of corneal epithelium; with application of chelating agent (eg, EDTA) | YES | YES | -- | YES |
| 65778 | Cover eye with membrane | YES | YES | YES | YES |
| 67820 | Correction of trichiasis; epilation, by forceps only | YES | YES | YES | YES |
| 67938 | Removal of embedded foreign body, eyelid | YES | YES | YES | YES |
| 68040 | Expression of conjuctival follicles | YES | YES | -- | YES |
| 68761 | Punctual plugs | YES | YES | YES | YES |
| Code | Description | Fully Funded Reimb. | Self- Funded Reimb. | Healthy Michigan Plan/ Medicaid Reimb. |
Medicare Reimb. |
| 68801 | Dilation of lacrimal punctum (service included surgical procedure only) | YES | YES | YES | YES |
| 76510 | Ophthalmic ultrasound, diagnostic, B-scan and quantitative A-scan performed during the same patient encounter | YES | YES | YES | YES |
| 76511 | Ophthalmic ultrasound | YES | YES | YES | YES |
| 76512 | Cont B-scan (with or without simultaneous A-scan) | YES | YES | YES | YES |
| 76513 | Ophthalmic ultrasound, diagnostic; anterior segment ultrasound, immersion (water bath) b-scan or high resolution biomicroscopy | YES | YES | YES | YES |
| 76514 | Distinguish glaucoma risk | YES | YES | YES | YES |
| 76516 | Ophthalmic biometry by ultrasound | YES | YES | YES | YES |
| 76519 | With intraocular lens power calculation | YES | YES | YES | YES |
| 76529 | Ophthalmic ultrasonic foreign body localization | YES | YES | YES | YES |
| G0117 | Glaucoma screening for high-risk patients furnished by an OD/MD/DO | YES | YES | YES | YES |
| G0118 | Glaucoma screening for high-risk patients, under the supervision of an OD/MD/DO | YES | YES | YES | YES |
| S0620 | Includes refraction code 92015. Do not bill 92015 separately | YES | YES | YES | YES |
| Code | Description | Fully Funded Reimb. | Self- Funded Reimb. | Healthy Michigan Plan/ Medicaid Reimb. |
Medicare Reimb. |
| S0621 | S0621 includes refraction code 92015. Do not bill 92015 separately. | YES | YES | YES | YES |
| 83516 | Immunoassay Nonantibody | YES | YES | YES | YES |
| 92002 | Ophthalmological services; medical examination and evaluation | YES | YES | YES | YES |
| 92004 | Comprehensive, new patient | -- | -- | -- | YES |
| 92012 | Ophthalmological services; medical exam and eval with initiation or continuation of diagnostic and treatment, intermediate | YES | YES | YES | YES |
| 92014 | Comprehensive, established patient, one or more | -- | -- | -- | YES |
| 92015 | Refraction | -- | -- | -- | YES |
| 92020 | Gonioscopy (separate procedure) | YES | YES | YES | YES |
| 92025 | Computerized corneal topography, unilateral or bilateral, with interpretation and report | YES | YES | YES | YES |
| 92060 | Sensorimotor exam with multiple measurements | YES | YES | YES | YES |
| Code | Description | Fully Funded Reimb. | Self- Funded Reimb. | Healthy Michigan Plan/ Medicaid Reimb. |
Medicare Reimb. |
| 92071 | Fitting of contact lens for treatment of disease (requires auth from Priority Health) | YES | YES | YES | YES |
| 92072 | Fitting of contact lens for management of keratoconus, initial fitting | YES | YES | YES | YES |
| 92081 | Visual field exam, unilateral or bilateral | YES | YES | YES | YES |
| 92082 | Intermediate exam (eg. at least 2 isopters on Goldmann perimeter) | YES | YES | YES | YES |
| 92083 | Extended examination | YES | YES | YES | YES |
| 92100 | Serial tonometry (separate procedure) with multiple measurements | YES | YES | YES | YES |
| 92132 | Scanning computerized ophthalmic diagnostic imaging, anterior segment, with interpretation and report, unilateral or bilateral | YES | YES | YES | YES |
| 92133 | Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; optic nerve | YES | YES | YES | YES |
| 92136 | Ophthalmic biometry by partial coherence interferometry with intraocular lens power calculation | -- | -- | -- | YES |
| Code | Description | Fully Funded Reimb. | Self- Funded Reimb. | Healthy Michigan Plan/ Medicaid Reimb. |
Medicare Reimb. |
| 92225 | Ophthalmoscopy, extended, with retinal drawing | YES | YES | YES | YES |
| 92226 | Ophthalmoscopy, subsequent with retinal drawing | YES | YES | YES | YES |
| 92227 | Remote imaging for detection of retinal disease (eg, retinopathy in a patient with diabetes) with analysis and report under physician supervision, unilateral or bilateral | YES | YES | YES | YES |
| 92228 | Remote imaging for monitoring and management of active retinal disease (eg, diabetic retinopathy) with physician review, interpretation and report, unilateral or bilateral | YES | YES | YES | YES |
| 92235 | Fluorescien angioscophy (includes multiframe imaging) with interpretation and report | YES | YES | -- | YES |
| 92250 | Fundus photography with interpretation | YES | YES | YES | YES |
| 92260 | Ophthalmodynamometry | YES | YES | YES | YES |
| 92270 | Electro-oculography with interpretation and report | YES | YES | YES | YES |
| 92275 | Electroculography with interpretation and report | YES | YES | YES | YES |
| 92283 | Color vision examination | YES | YES | YES | YES |
| 92284 | Dark adaptation examination with interpretation | YES | YES | YES | YES |
| 92285 | External ocular photography with interpretation and report for documentation of medical progress (eg, close-up photography, slit lamp photography, goniophotography, stereophotgraphy | YES | YES | YES | YES |
| 92286 | External ocular photography with interpretation and report, with spcular endothelial microscopy and cell count | YES | YES | YES | YES |
| 92287 | Special anterior segment photography with interpretation and report; with fluorescein angiography | YES | YES | YES | YES |
| 92310 | Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens both eyes, except for aphakia | YES- | YES | YES | -- |
| Code | Description | Fully Funded Reimb. | Self- Funded Reimb. | Healthy Michigan Plan/ Medicaid Reimb. |
Medicare Reimb. |
| 92311* | Corneal lens for aphakia, one eye | YES | YES | YES | YES |
| 92312* | Corneal lens for aphakia, both eyes | YES | YES | YES | YES |
| 92313 | Corneoscleral lens | YES | YES | YES | YES |
| 92315 | Prescription of optical and physical characteristics of contact lenses, with medical supervision of adaptation and fitting by independent technician; corneal lens for aphakia, one eye | YES | YES | -- | YES |
| 92316 | Prescription of optical and physical characteristics of contact lenses, with medical supervision of adaptation and fitting by independent technician; corneal lens for aphakia, both eyes | YES | YES | -- | YES |
| 92325 | Modification of contact lens (separate procedure), with medical supervision of adaptation | YES | YES | -- | YES |
| 92326 | Replacement of contact lens | YES | YES | YES | YES |
| 92340 | Fitting of spectacles, except for aphakia; monofocal | YES | YES | YES | -- |
| 92341 | Fitting of spectacles, except for aphakia; bifocal | YES | YES | YES | -- |
| 92342 | Fitting of spectacles, except for aphakia; multifocal other than bifocal | YES | YES | YES | -- |
| Code | Description | Fully Funded Reimb. | Self- Funded Reimb. | Healthy Michigan Plan/ Medicaid Reimb. |
Medicare Reimb. |
| 92352 | Fitting of spectacle prosthesis for aphakia; monofocal | YES | YES | YES | -- |
| 92353 | Fitting of spectacle prosthesis for aphakia; multifocal | YES | YES | YES | -- |
| 92370 | Repair and adjust spectacles | YES | YES | YES | -- |
| 95060 | Ophthalmic mucous membrane tests | YES | YES | YES | YES |
| 95930 | Visual evoked potential (vep) testing central nervous system, checkerboard or flash | YES | YES | YES | YES |
| 97112 | Therapeutic procedure, one or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities | YES | YES | YES | YES |
| 97116 | Therapeutic procedure, one or more areas, each 15 minutes; gain training (includes stair climbing) | YES | YES | -- | YES |
| 97530 | Therapeutic activities, direct (one-on-one) patient contact by the provider (use of dynamic activities to improve functional performance), each 15 minutes | YES | YES | YES | YES |
| 99201 | Office/outpatient visit, new | YES | YES | YES | YES |
| 99202 | Office/outpatient visit, new | YES | YES | YES | YES |
| 99203 | Office/outpatient visit, new | YES | YES | YES | YES |
| 99204 | Office/outpatient visit, new | YES | YES | YES | YES |
| 99205 | Office/outpatient visit, new | YES | YES | YES | YES |
| Code | Description | Fully Funded Reimb. | Self- Funded Reimb. | Healthy Michigan Plan/ Medicaid Reimb. |
Medicare Reimb. |
| 99211 | Office/outpatient visit, established | YES | YES | YES | YES |
| 99212 | Office/outpatient visit, established | YES | YES | YES | YES |
| 99213 | Office/outpatient visit, established | YES | YES | YES | YES |
| 99214 | Office/outpatient visit, established | YES | YES | YES | YES |
| 99215 | Office/outpatient visit, established | YES | YES | YES | YES |
| 99241 | Office/outpatient visit, established | YES | YES | YES | -- |
| 99242 | Office consultation requiring 3 components | YES | YES | YES | -- |
| 99243 | Office consultation requiring 3 components | YES | YES | YES | -- |
| Code | Description | Fully Funded Reimb. | Self- Funded Reimb. | Healthy Michigan Plan/ Medicaid Reimb. |
Medicare Reimb. |
| 99244 | Office consultation requiring 3 components | YES | YES | YES | YES |
| 99245 | Office consultation requiring 3 components | YES | YES | YES | YES |
| 99251 | Initial inpatient consultation | YES | YES | YES | -- |
| 99252 | Initial inpatient consultation | YES | YES | YES | -- |
| 99253 | Initial inpatient consultation | YES | YES | YES | -- |
| 99254 | Initial inpatient consultation | YES | YES | YES | -- |
| 99255 | Initial inpatient consultation | YES | YES | YES | -- |
* Limitations of coverage apply. Contact Provider Services for more information.