Optometrist scope of service

Page last updated on: 6/13/25

Applies to:

All plans

Medicare plans follow Medicare coverage and billing rules

Medical policy

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 Medicaid members

Routine vision services for all Priority Health commercial, Medicaid 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 (login required).

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.

92201

Ophthalmoscopy, extended, with retinal drawing

YES

YES

YES

YES

92202

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

Diagnostic dark adaptation examination with interpretation and report

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

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

99242

Office/outpatient consultation for new or established patient

YES

YES

YES

--

99243

Office/outpatient consultation for new or established patient

YES

YES

YES

--

Code

Description

Fully Funded Reimb.

Self- Funded Reimb.

Healthy
Michigan Plan/ Medicaid Reimb.

Medicare Reimb.

99244

Office/outpatient consultation for new or established patient

YES

YES

YES

YES

99245

Office/outpatient consultation for new or established patient

YES

YES

YES

YES

99252

Inpatient/observation consultation for new or established patient

YES

YES

YES

--

99253

Inpatient/observation consultation for new or established patient

YES

YES

YES

--

99254

Inpatient/observation consultation for new or established patient

YES

YES

YES

--

99255

Inpatient/observation consultation for new or established patient

YES

YES

YES

--

* Limitations of coverage apply. Contact Provider Services for more information.