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 YES
65430 Scraping of cornea, diagnostic, for smear -- -- -- YES
65435 Removal of corneal epithelium; with or without chemocauterization (abrasion, curettage) -- -- -- YES
65436 Removal of corneal epithelium; with application of chelating agent (eg, EDTA) YES YES -- YES
65600 Multiple punctures of anterior cornea (eg, for corneal erosion, tattoo) 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
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) -- -- -- --
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
92072 Fitting of contact lens for management of keratoconus, initial fitting -- -- -- 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
92140 Provocative tests for glaucoma, with interpretation and report, without tonography -- -- -- 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 -- -- -- --
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 N/A 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 N/A YES
92325 Modification of contact lens (separate procedure), with medical supervision of adaptation YES YES -- YES
92326 Replacement of contact lens 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 --
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
99172 Visual function screening, automated or semi-automated bilateral quantitative determination of visual acuity, ocular alignment, color vision by pseudoisochromatic plates, and field of vision YES YES -- --
99173 Screening test of visual acuity, quantitative, bilateral 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.