Archived SECTION 19 - PROCEDURE CODES. Section 19 - Procedure Codes

Transcription

1 SECTION 19 - EDURE CODES 19.1 CPT AND HCPCS CODES PARTICIPANT COST SHARING AND COPAY HCY/EPSDT VISION SCREENING OPTICAL EDURE CODES A EYE EXAMINATIONS B FRAMES C SINGLE VISION LENSES, GLASS OR PLASTIC D BIFOCAL LENSES, GLASS OR PLASTIC E TRIFOCAL LENSES, GLASS OR PLASTIC F VARIABLE ASPHERICITY LENS, GLASS OR PLASTIC G CONTACT LENSES H PROSTHETIC EYE I REPAIR OF PROSTHETIC EYE J MISCELLANEOUS K HEALTHY CHILDREN AND YOUTH (HCY) SURGICAL EDURES POST-OPERATIVE CATARACT CARE DIAGNOSTIC ULTRASOUND GENERAL OPHTHALMOLOGICAL SERVICES SPECIAL OPTICAL SERVICES OCULAR PROSTHETICS, ARTIFICIAL EYE SPECTACLE SERVICES MISCELLANEOUS SERVICES EVALUATION AND MANAGEMENT SERVICES A OFFICE VISIT NEW PATIENT B OFFICE VISIT ESTABLISHED PATIENT C HOSPITAL INPATIENT SERVICES D SUBSEQUENT HOSPITAL CARE ##2010 1

2 19.13.E OFFICE OR OTHER OUTPATIENT CONSULTATIONS NEW OR ESTABLISHED PATIENT F INITIAL INPATIENT CONSULTATIONS NEW OR ESTABLISHED PATIENT G FOLLOW-UP INPATIENT CONSULTATIONS ESTABLISHED PATIENT H CONFIRMATORY CONSULTATIONS NEW OR ESTABLISHED PATIENT I EMERGENCY DEPARTMENT SERVICES NEW OR ESTABLISHED PATIENT J COMPREHENSIVE NURSING FACILITY ASSESSMENTS (NF) K NEW OR ESTABLISHED PATIENT L NEW PATIENT M ESTABLISHED PATIENT N HOME SERVICES NEW PATIENT O HOME SERVICES ESTABLISHED PATIENT ##2010

3 SECTION 19-EDURE CODES Procedure codes used by MO HealthNet are identified as HCPCS codes (Health Care Procedure Coding System). The HCPCS is divided into three subsystems, referred to as level I, level II and level III. Level I is comprised of Current Procedural Terminology (CPT) codes that are used to identify medical services and procedures furnished by physicians and other health care professionals. Level II is comprised of the HCPCS National Level II codes that are used primarily to identify products, supplies and services not included in the CPT codes. Level III codes have been developed by MO HealthNet State agencies for use in specific programs. NOTE: Replacement of level III codes is required by the Health Insurance Portability and Accountability act of 1996 (HIPAA). Providers should reference bulletins for code replacement information. Reference materials regarding the Healthcare Common Procedure Coding System (HCPCS), and Current Procedural Terminology (CPT) may be obtained through the American Medical Association at: Order Department American Medical Association P.O. Box Atlanta, GA Telephone Number: (800) AMA Members: (800) Fax Orders: (312) CPT AND HCPCS CODES A copy of the Current Procedural Terminology (CPT) and the Health Care Common Procedure Coding System (HCPCS) may be purchased at a local bookstore or medical supply company PARTICIPANT COST SHARING AND COPAY Participants age 18 and over are subject to a cost sharing amount unless an exemption applies. Refer to Section 13.9.A, 13.9.B, 13.9.C and 13.9.D for additional information on cost sharing amounts to be collected and exemptions to the cost sharing requirement. Refer to Section 13.9.E, 13.9.E(1), 13.9.E(2), 3-10##2010

4 and 13.9.E(3), for additional information on copay amounts to be collected and exemptions to the copay requirement. Participant cost sharing is based on the lower sum that of charges shown on the claim or the MO HealthNet allowable fees for covered service according to the schedule below. $10.00 or less $.50 $11.00-$25.99 $1.00 $26.00-$50.99 $2.00 $51.00 or more $3.00 The following Participants or conditions are exempt from the cost sharing requirement. Participants under age 18; Foster Care Children up to 21 years; Hospice Participants; Services to participants residing in a skilled nursing facility, a psychiatric hospital, a residential care facility or an adult boarding home; MO HealthNet managed care health plan enrollees for services provided by the MO HealthNet managed care health plan. Individuals with an ME code of 74 must pay a $5.00 copay and ME code "75" must pay a $10.00 copay for identified services. The copay amount applies whether the individual receives services on a fee-for-service basis or is enrolled in an MO HealthNet managed care health plan. Refer to Sections 13.9.E, 13.9.E(1), 13.9.E(2) and 13.9.E(3) for additional information on copay amounts and exemptions HCY/EPSDT VISION SCREENING PRO C COD E The vision partial screen may be provided by the following enrolled MO HealthNet provider: Optometrist MOD DESCRIPTION MAXIMU M ALLOWE D Vision Screening None $ UC Vision Screening with EPSDT referral None $ ##2010

5 This screen can include observation for blinking, tracking, corneal light reflex, pupillary response, ocular movements. To test for visual acuity, use the Cover test for children under 3 years of age. For children over 3 years of age utilize the Snellen Vision Chart. (See Section 9 for information on Healthy Children and Youth Program) OPTICAL EDURE CODES 19.4.A EYE EXAMINATIONS G0117 Glaucoma screening for high risk patients furnished by an optometrist or ophthalmologist (May not be billed on the same date of service as any office visit or eye examination) G0118 Glaucoma screening for high risk patient furnished under the direct supervision of an optometrist or ophthalmologist (May not be billed on the same date of service as any office visit or eye examination) S0592 Comprehensive contact lens/lenses evaluation (May be billed in addition to an eye exam on the same date of service) S0620 Routine ophthalmological exam including refraction; new patient; complete exam S Routine ophthalmological exam including refraction; new patient; limited exam S0621 Routine ophthalmological exam including refraction; established patient; complete exam S Routine ophthalmological exam including refraction; established patient; limited exam None $24.87 None $17.48 MNF $20.00 None $53.00 None $30.00 None $53.00 None $30.00 MN, Certificate of Medical Necessity; MNF, Certificate of Medical Necessity on File 19.4.B FRAMES 5-10##2010

6 V2020* Frames None $20.00 V2020* 22 Special frames None $35.00 * These are the only services an optician can perform C SINGLE VISION LENSES, GLASS OR PLASTIC V2100* RT Sphere, single vision; plano to plus or minus 4.00, V2100* LT Sphere, single vision; plano to plus or minus 4.00, V2101* RT Sphere, single vision; plus or minus 4.12 to plus or minus 7.00d, V2101* LT Sphere, single vision; plus or minus 4.12 to plus or minus 7.00d, V2102* RT Sphere, single vision; plus or minus 7.12 to plus or minus 20.00d, V2102* LT Sphere, single vision; plus or minus 7.12 to plus or minus 20.00d, V2103* RT Spherocylinder, single vision, plano to plus or minus 4.00d sphere;.12 to 2.00d cylinder, per lens V2103* LT Spherocylinder, single vision, plano to plus or minus 4.00d sphere;.12 to 2.00d cylinder, per lens V2104* RT Spherocylinder, single vision, plano to plus or minus 4.00d sphere; 2.12 to 4.00d cylinder, per lens V2104* LT Spherocylinder, single vision, plano to plus or minus 4.00d sphere; 2.12 to 4.00d cylinder, per lens V2105* RT Spherocylinder, single vision, plano to plus or minus 4.00d sphere; 4.25 to 6.00d cylinder, per lens V2105* LT Spherocylinder, single vision, plano to plus or minus 4.00d sphere; 4.25 to 6.00d cylinder, per lens None $11.00 None $11.00 None $23.00 None $23.00 None $34.50 None $34.50 None $11.00 None $11.00 None $23.00 None $23.00 None $31.00 None $ ##2010

7 V2106* RT Spherocylinder, single vision, plano to plus or None $35.75 minus 4.00d sphere; over 6.00d cylinder, per lens V2106* LT Spherocylinder, single vision, plano to plus or None $35.75 minus 4.00d sphere; over 6.00d cylinder, per lens V2107* RT Spherocylinder, single vision, plus or minus None $ d to plus or minus 7.00d sphere;.12 to 2.00d V2107* LT Spherocylinder, single vision, plus or minus None $ d to plus or minus 7.00d sphere;.12 to 2.00d V2108* RT Spherocylinder, single vision, plus or minus None $ d to plus or minus 7.00d sphere; 2.12 to 4.00d V2108* LT Spherocylinder, single vision, plus or minus None $ d to plus or minus 7.00d sphere; 2.12 to 4.00d V2109* RT Spherocylinder, single vision, plus or minus None $ d to plus or minus 7.00d sphere; 4.25 to 6.00d V2109* LT Spherocylinder, single vision, plus or minus None $ d to plus or minus 7.00d sphere; 4.25 to 6.00d V2110* RT Spherocylinder, single vision, plus or minus None $ d to plus or minus 7.00d sphere; over 6.00d V2110* LT Spherocylinder, single vision, plus or minus None $ d to plus or minus 7.00d sphere; over 6.00d V2111* RT Spherocylinder, single vision, plus or minus None $ d to plus or minus 12.00d sphere;.25 to 2.25d V2111* LT Spherocylinder, single vision, plus or minus None $ d to plus or minus 12.00d sphere;.25 to 2.25d V2112* RT Spherocylinder, single vision, plus or minus None $ d to plus or minus 12.00d sphere; 2.25d to 4.00d V2112* LT Spherocylinder, single vision, plus or minus None $ d to plus or minus 12.00d sphere; 2.25d to 4.00d V2113* RT Spherocylinder, single vision, plus or minus None $ ##2010

8 7.25d to plus or minus 12.00d sphere; 4.25 to 6.00d V2113* LT Spherocylinder, single vision, plus or minus None $ d to plus or minus 12.00d sphere; 4.25 to 6.00d V2114* RT Spherocylinder, single vision, sphere over plus None $54.00 or minus 12.00d V2114* LT Spherocylinder, single vision, sphere over plus None $54.00 or minus 12.00d V2115* RT Lenticular, (myodisc),, single vision None $86.25 V2115* LT Lenticular, (myodisc),, single vision None $86.25 V2116* RT Lenticular lens, nonaspheric,, single None $86.25 vision V2116* LT Lenticular lens, nonaspheric,, single None $86.25 vision V2117* RT Lenticular, aspheric,, single vision None $86.25 V2117* LT Lenticular, aspheric,, single vision None $86.25 V2118* RT Aniseikonic lens, single vision None $86.25 V2118* LT Aniseikonic lens, single vision None $86.25 V2121* RT Lenticular lens,, single None $86.25 V2121* LT Lenticular lens,, single None $86.25 V2199* RT Not otherwise classified, single vision lens MN, IofC MP V2199* LT Not otherwise classified, single vision lens MN, IofC MP MP, Manually Priced; MN, Certificate of Medical Necessity; IofC, Manufacturer's Invoice of Cost * These are the only services an optician can perform D BIFOCAL LENSES, GLASS OR PLASTIC V2200* RT Sphere, bifocal, plano to plus or minus 4.00d, V2200* LT Sphere, bifocal, plano to plus or minus 4.00d, V2201* RT Sphere, bifocal, plus or minus 4.12 to plus or minus 7.00d, V2201* LT Sphere, bifocal, plus or minus 4.12 to plus or minus 7.00d, None $30.50 None $30.50 None $39.00 None $ ##2010

9 V2202* RT Sphere, bifocal, plus or minus 7.12 to plus or minus 20.00d, V2202* LT Sphere, bifocal, plus or minus 7.12 to plus or minus 20.00d, V2203* RT Spherocylinder, bifocal, plano to plus or minus 4.00d sphere;.12 to 2.00d cylinder, V2203* LT Spherocylinder, bifocal, plano to plus or minus 4.00d sphere;.12 to 2.00d cylinder, V2204* RT Spherocylinder, bifocal, plano to plus or minus 4.00d sphere; 2.12 to 4.00d cylinder, V2204* LT Spherocylinder, bifocal, plano to plus or minus 4.00d sphere; 2.12 to 4.00d cylinder, V2205* RT Spherocylinder, bifocal, plano to plus or minus 4.00d sphere; 4.25 to 6.00d cylinder, V2205* LT Spherocylinder, bifocal, plano to plus or minus 4.00d sphere; 4.25 to 6.00d cylinder, V2206* RT Spherocylinder, bifocal, plano to plus or minus 4.00d sphere; over 6.00d cylinder, per lens V2206* LT Spherocylinder, bifocal, plano to plus or minus 4.00d sphere; over 6.00d cylinder, per lens V2207* RT Spherocylinder, bifocal, plus or minus 4.25 to plus or minus 7.00d sphere;.12 to 2.00d V2207* LT Spherocylinder, bifocal, plus or minus 4.25 to plus or minus 7.00d sphere;.12 to 2.00d V2208* RT Spherocylinder, bifocal, plus or minus 4.25 to plus or minus 7.00d sphere; 2.12 to 4.00d V2208* LT Spherocylinder, bifocal, plus or minus 4.25 to plus or minus 7.00d sphere; 2.12 to 4.00d V2209* RT Spherocylinder, bifocal, plus or minus 4.25 to plus or minus 7.00d sphere; 4.25 to 6.00d None $51.75 None $51.75 None $30.50 None $30.50 None $39.00 None $39.00 None $40.25 None $40.25 None $47.00 None $47.00 None $40.25 None $40.25 None $42.50 None $42.50 None $ ##2010

10 V2209* LT Spherocylinder, bifocal, plus or minus 4.25 to None $46.00 plus or minus 7.00d sphere; 4.25 to 6.00d V2210* RT Spherocylinder, bifocal, plus or minus 4.25 to None $53.00 plus or minus 7.00d sphere; over 6.00d V2210* LT Spherocylinder, bifocal, plus or minus 4.25 to None $53.00 plus or minus 7.00d sphere; over 6.00d V2211* RT Spherocylinder, bifocal, plus or minus 7.25 to None $54.00 plus or minus 12.00d sphere;.25 to 2.25d V2211* LT Spherocylinder, bifocal, plus or minus 7.25 to None $54.00 plus or minus 12.00d sphere;.25 to 2.25d V2212* RT Spherocylinder, bifocal, plus or minus 7.25 to None $54.00 plus or minus 12.00d sphere; 2.25 to 4.00d V2212* LT Spherocylinder, bifocal, plus or minus 7.25 to None $54.00 plus or minus 12.00d sphere; 2.25 to 4.00d V2213* RT Spherocylinder, bifocal, plus or minus 7.25 to None $54.00 plus or minus 12.00d sphere; 4.25 to 6.00d V2213* LT Spherocylinder, bifocal, plus or minus 7.25 to None $54.00 plus or minus 12.00d sphere; 4.25 to 6.00d V2214* RT Spherocylinder, bifocal, sphere over plus or None $69.00 minus 12.00d, V2214* LT Spherocylinder, bifocal, sphere over plus or None $69.00 minus 12.00d, V2215* RT Lenticular (myodisc),, bifocal None $ V2215* LT Lenticular (myodisc),, bifocal None $ V2218 RT Aniseikonic,, bifocal None $ * V2218 LT Aniseikonic,, bifocal None $ * V2219 RT Bifocal seg width over 28mm None $31.25 * V2219 * LT Bifocal seg width over 28mm None $31.25 V2220 RT Bifocal add over 3.25d None $ ##2010

11 * V2220 * V2299 * V2299 * LT Bifocal add over 3.25d None $23.00 RT Specialty bifocal MN, IofC MP LT Specialty bifocal MN, IofC MP MP, Manually Priced; MN, Certificate of Medical Necessity; IofC, Manufacturer's Invoice of Cost * These are the only services an optician can perform E TRIFOCAL LENSES, GLASS OR PLASTIC V2300* RT Sphere, trifocal, plano to plus or minus 4.00d, None $50.00 V2300* LT Sphere, trifocal, plano to plus or minus 4.00d, None $50.00 V2301* RT Sphere, trifocal, plus or minus 4.12 to plus or None $63.25 minus 7.00d, V2301* LT Sphere, trifocal, plus or minus 4.12 to plus or None $63.25 minus 7.00d, V2302* RT Sphere, trifocal, plus or minus 7.12, to plus or None $65.50 minus 20.00, V2302* LT Sphere, trifocal, plus or minus 7.12, to plus or None $65.50 minus 20.00, V2303* RT Spherocylinder, trifocal, plano to plus or minus None $ d, sphere;.12 to 2.00d V2303* LT Spherocylinder, trifocal, plano to plus or minus None $ d, sphere;.12 to 2.00d V2304* RT Spherocylinder, trifocal, plano to plus or minus None $ d, sphere; 2.25 to 4.00d V2304* LT Spherocylinder, trifocal, plano to plus or minus None $ d, sphere; 2.25 to 4.00d V2305* RT Spherocylinder, trifocal, plano to plus or minus None $ d, sphere; 4.25 to 6.00d V2305* LT Spherocylinder, trifocal, plano to plus or minus None $ d, sphere; 4.25 to 6.00d V2306* RT Spherocylinder, trifocal, plano to plus or minus None $ ##2010

12 4.00d, sphere; over 600d V2306* LT Spherocylinder, trifocal, plano to plus or minus None $ d, sphere; over 600d V2307* RT Spherocylinder, trifocal, plus or minus 4.25 to None $63.25 plus or minus 7.00d sphere, ;.12 to 2.00d V2307* LT Spherocylinder, trifocal, plus or minus 4.25 to None $63.25 plus or minus 7.00d sphere; 12 to 2.00d V2308* RT Spherocylinder, trifocal, plus or minus 4.25 to None $63.25 plus or minus 7.00d sphere; 2.12 to 4.00d V2308* LT Spherocylinder, trifocal, plus or minus 4.25 to None $63.25 plus or minus 7.00d sphere; 2.12 to 4.00d V2309* RT Spherocylinder, trifocal, plus or minus 4.25 to None $71.25 plus or minus 7.00d sphere; 4.25 to 6.00d V2309* LT Spherocylinder, trifocal, plus or minus 4.25 to None $71.25 plus or minus 7.00d sphere; 4.25 to 6.00d V2310* RT Spherocylinder, trifocal, plus or minus 4.25 to None $74.75 plus or minus 7.00d sphere;; over 6.00d V2310* LT Spherocylinder, trifocal, plus or minus 4.25 to None $74.75 plus or minus 7.00d sphere;; over 6.00d V2311* RT Spherocylinder, trifocal, plus or minus 7.25, to None $69.00 plus or minus 12.00d sphere;.25 to 2.25d V2311* LT Spherocylinder, trifocal, plus or minus 7.25, to None $69.00 plus or minus 12.00d sphere;.25 to 2.25d V2312* RT Spherocylinder, trifocal, plus or minus 7.25, to None $69.00 plus or minus 12.00d sphere; 2.25 to 4.00d V2312* LT Spherocylinder, trifocal, plus or minus 7.25, to None $69.00 plus or minus 12.00d sphere; 2.25 to 4.00d V2313* RT Spherocylinder, trifocal, plus or minus 7.25, to None $74.75 plus or minus 12.00d sphere; 4.25 to 6.00d V2313* LT Spherocylinder, trifocal, plus or minus 7.25, to None $ ##2010

13 plus or minus 12.00d sphere; 4.25 to 6.00d V2314* RT Spherocylinder, trifocal, sphere over plus or None $86.25 minus 12.00d, V2314* LT Spherocylinder, trifocal, sphere over plus or None $86.25 minus 12.00d, V2315* RT Lenticular (myodisc),, trifocal None $ V2315* LT Lenticular (myodisc),, trifocal None $ V2318* RT Aniseikonic,, trifocal None $ V2318* LT Aniseikonic,, trifocal None $ V2319* RT Trifocal seg width over 28mm None $63.25 V2319* LT Trifocal seg width over 28mm None $63.25 V2320* RT Trifocal add over 3.25d None $34.50 V2320* LT Trifocal add over 3.25d None $34.50 V2321* RT Lenticular lens,, trifocal None $87.75 V2321* LT Lenticular lens,, trifocal None $87.75 V2399* RT Specialty trifocal MN, IofC MP V2399* LT Specialty trifocal MN, IofC MP MP, Manually Priced; MN, Certificate of Medical Necessity; IofC, Manufacturer's Invoice of Cost * These are the only services an optician can perform F VARIABLE ASPHERICITY LENS, GLASS OR PLASTIC V2410* RT Variable asphericity lens; single vision, full None $86.25 field, glass or plastic, V2410* LT Variable asphericity lens; single vision, full None $86.25 field, glass or plastic, V2430* RT Variable asphericity lens; bifocal, full field, None $86.25 glass or plastic, V2430* LT Variable asphericity lens; bifocal, full field, None $86.25 glass or plastic, V2499* RT Variable asphericity lens; other type MNF $86.25 V2499* LT Variable asphericity lens; other type MNF $ ##2010

14 MP, Manually Priced; MN, Certificate of Medical Necessity; IofC, Manufacturer's Invoice of Cost; MNF, Certificate of Medical Necessity on File * These are the only services an optician can perform G CONTACT LENSES V2500* RT Contact lens, PMMA; spherical, MNF $16.00 V2500* LT Contact lens, PMMA; spherical, MNF $16.00 V2501* RT Contact lens, PMMA; toric or prism ballast, per MNF $39.00 lens V2501* LT Contact lens, PMMA; toric or prism ballast, per MNF $39.00 lens V2502* RT Contact lens, PMMA; bifocal, MNF $ V2502* LT Contact lens, PMMA; bifocal, MNF $ V2510* RT Contact lens, gas permeable; spherical, MNF $46.00 V2510* LT Contact lens, gas permeable; spherical, MNF $46.00 V2511* RT Contact lens, gas permeable; toric, prism ballast, V2511* LT Contact lens, gas permeable; toric, prism ballast, MNF MNF V2512* RT Contact lens, gas permeable; bifocal, MNF V2512* LT Contact lens, gas permeable; bifocal, MNF V2520* RT Contact lens hydrophilic; spherical, MNF V2520* LT Contact lens hydrophilic; spherical, MNF V2521* RT Contact lens hydrophilic; toric or prism ballast, V2521* LT Contact lens hydrophilic; toric or prism ballast, MNF MNF $68.00 $68.00 $ $ $28.00 $28.00 $65.00 $ ##2010

15 V2522* RT Contact lens hydrophilic; bifocal, MNF V2522* LT Contact lens hydrophilic; bifocal, MNF V2530* RT Contact lens, scleral, gas impermeable, MNF V2530* LT Contact lens, scleral, gas impermeable, MNF V2531* RT Contact lens, scleral, gas permeable, MNF V2531* LT Contact lens, scleral, gas permeable, MNF V2599* RT Contact lens, other type MN, IofC V2599* LT Contact lens, other type MN, IofC $95.00 $95.00 $66.00 $66.00 $76.00 $76.00 MP MP MP, Manually Priced; MN, Certificate of Medical Necessity; IofC, Manufacturer's Invoice of Cost; MNF, Certificate of Medical Necessity on File * These are the only services an optician can perform H PROSTHETIC EYE V2623** RT Prosthetic eye, plastic, custom None $ V2623** LT Prosthetic eye, plastic, custom None $ V2624** RT Polishing/resurfacing or ocular prosthesis None $10.25 V2624** LT Polishing/resurfacing or ocular prosthesis None $10.25 ** These are the only services an ocularist can perform I REPAIR OF PROSTHETIC EYE 15-10##2010

16 V2625** RT Enlargement of ocular prosthesis None $ V2625** LT Enlargement of ocular prosthesis None $ V2626** RT Reduction of ocular prosthesis None $ V2626** LT Reduction of ocular prosthesis None $ V2627** RT Scleral cover shell None $ V2627** LT Scleral cover shell None $ V2628** RT Fabrication and fitting of ocular conformer None $ V2628** LT Fabrication and fitting of ocular conformer None $ ** These are the only services an ocularist can perform J MISCELLANEOUS V2784* RT Polycarbonate lens MN $15.00 V2784* LT Polycarbonate lens MN $15.00 S0581* RT Nonstandard lens MN, IofC MP S0581* LT Nonstandard lens MN, IofC MP V2700* RT Balance lens, None $37.29 V2700* LT Balance lens, None $37.29 V2710* RT Slab off prism, glass or plastic, None $66.75 V2710* LT Slab off prism, glass or plastic, None $66.75 V2715* RT Prism, None $10.25 V2715* LT Prism, None $10.25 V2718* RT Press-on lens, fresnell prism, None $46.50 V2718* LT Press-on lens, fresnell prism, None $46.50 V2730* RT Special base curve, glass or plastic, None $34.50 V2730* LT Special base curve, glass or plastic, None $34.50 V2744* RT Tint; photchromatic, (Includes None $5.00 transition lens) V2744* LT Tint; photchromatic, (Includes None $5.00 transition lens) V2745* RT Tint, any color, solid, gradient or equal None $1.88 V2745* LT Tint, any color, solid, gradient or equal None $1.88 V2750* RT Anti-reflective coating, Covered only after $ ##2010

17 cataract surgery V2750* LT Anti-reflective coating, Covered only after $40.25 cataract surgery V2755* RT U-V lens, Covered only after $8.75 cataract surgery V2755* LT U-V lens, Covered only after $8.75 cataract surgery V2761* RT Mirror coating, any type, solid, gradient or None $20.00 equal, any lens material, V2761* LT Mirror coating, any type, solid, gradient or None $20.00 equal, any lens material, V2770* RT Occluder lens, None $23.00 V2770* LT Occluder lens, None $23.00 V2780* RT Oversize lens, (Used if the eye size is None $ or greater) V2780* LT Oversize lens, (Used if the eye size is None $ or greater) V2781* RT Progressive lens, Only covered if $37.25 replacing progressive lens V2781* LT Progressive lens, Only covered if $37.25 replacing progressive lens V2797* Vision supply, accessory and/or service component of another HCPCS vision code None MP MP, Manually Priced; MN, Certificate of Medical Necessity; IofC, Manufacturer's Invoice of Cost * These are the only services an optician can perform K HEALTHY CHILDREN AND YOUTH (HCY) V2799 Vision Service, Miscellaneous PA MP PA, Prior Authorization Request 17-10##2010

18 19.5 SURGICAL EDURES NOTE: Surgical services are limited to a certified optometrist. For a complete description of each procedure code, refer to a current edition of the Physicians Current Procedural Terminology (CPT) Remove foreign body from eye None $ Remove foreign body from eye None $ Remove foreign body from eye None $ Remove foreign body from eye None $ Corneal smear None $ Curette/treat cornea None $ Revise eyelashes None $ Revise eyelashes None $ Treatment of eyelid lesions None $ Close tear duct opening None $ Dilate tear duct opening None $ Probe nasolacrimal duct None $ Explore/irrigate tear ducts None $ Unlisted procedure, lacrimal system None $ POST-OPERATIVE CATARACT CARE NOTE: Post-operative services are limited to an optometrist. For a complete description of each procedure code, refer to a current edition of the Physicians Current Procedural Terminology (CPT) Removal of lens lesion None $ Removal of lens material None $ Removal of lens material None $ Removal of lens material None $ Extraction of lens None $ Extraction of lens None $ Extraction of lens (other than 66840, 66850, 66852) None $ ##2010

19 Cataract surgery, complex None $ Cataract surg w/iol, 1 stage None $ Cataract surg w/iol, 1 stage None $ Insertion of lens prosthesis None $ Insertion of lens prosthesis None $ DIAGNOSTIC ULTRASOUND NOTE: Diagnostic ultrasound services are limited to an optometrist. For a complete description of each procedure code, refer to a current edition of the Physicians Current Procedural Terminology (CPT) Echo exam of eye None $ Echo exam of eye None $ Echo exam of eye None $ Echo exam of eye None $ Echo exam of eye None $ GENERAL OPHTHALMOLOGICAL SERVICES NOTE: These procedures are limited to an optometrist. For a complete description of each procedure code, refer to a current edition of the Physicians Current Procedural Terminology (CPT). CODE MOD DESCRIPTION Eye exam, new patient None $ Eye exam, new patient None $ Eye exam, established patient None $ Eye exam & treatment established patient None $ SPECIAL OPTICAL SERVICES NOTE: These procedures are limited to an optometrist. For a complete description of each procedure code, refer to a current edition of the Physicians Current Procedural Terminology (CPT) ##2010

20 92015 Refraction None $ Eye exam & treatment, under general anesthesia None $ Special eye evaluation None $ Special eye evaluation None $ Orthoptic/pleoptic training PA $ Fitting of contact lens for treatment of disease, MNF $80.00 including supply of lens Visual field examination None $ Visual field examination None $ Visual field examination None $ Serial tonometry exam None $ Tonography & eye evaluation None $ Water provocation tonography None $ Ophthalmic biometry None $ Glaucoma provocative tests None $ Special eye exam, initial None $ Special eye exam, subsequent None $ Eye exam with photos None $ Eye exam with photos None $ Ophthalmoscopy/dynamometry None $ Needle oculoelectromyography 1/more extra None $15.00 ocular muscles 1/both eyes with interpretation and report Electro-oculography PA $ Electroretinography None $ Color vision examination None $ Dark adaptation eye examination None $ Eye photography None $ Visual evoked potential test PA $75.00 PA, Prior Authorization Request; MN, Certificate of Medical Necessity; MP; Manually Priced OCULAR PROSTHETICS, ARTIFICIAL EYE 20-10##2010

21 For a complete description of each procedure code, refer to a current edition of the Physicians Current Procedural Terminology (CPT) Fitting of artificial eye None $ SPECTACLE SERVICES For a complete description of each procedure code, refer to a current edition of the Physicians Current Procedural Terminology (CPT) * Repair & adjust spectacles None $ * 52 Repair & adjust spectacles, temples only (If billing for two (2) temples on the same date of service, bill two units for this procedure code on the claim) None $3.00 * These are the only services an optician can perform. PA, Prior Authorization Request MISCELLANEOUS SERVICES For a complete description of each procedure code, refer to a current edition of the Physicians Current Procedural Terminology (CPT) Medical services after hours (May be billed in None $5.00 addition to the office visit) Medical services at night (May be billed in None $10.00 addition to the office visit) Medical services, unusual hours (May be billed None $10.00 in addition to the office visit) Non-office medical services None $ Office emergency care None $ Special supplies, except spectacles (list drugs, trays, supplies, or materials provided) (except Invoice of cost for the supplies must MP 21-10##2010

22 spectacles) be sent in with the paper claim. MP; Manually Priced EVALUATION AND MANAGEMENT SERVICES The following procedure codes are used to report evaluation and management services provided only by an optometrist in the office, in the hospital, or in an outpatient or other ambulatory facility. For a complete description of each procedure code, refer to a current edition of the Physicians Current Procedural Terminology (CPT) A OFFICE VISIT NEW PATIENT Office/outpatient visit, new None $ Office/outpatient visit, new None $ Office/outpatient visit, new None $ Office/outpatient visit, new None $ Office/outpatient visit, new None $ B OFFICE VISIT ESTABLISHED PATIENT Office/outpatient, established None $ Office/outpatient, established None $ Office/outpatient, established None $ Office/outpatient, established None $ Office/outpatient, established None $ C HOSPITAL INPATIENT SERVICES - 10##

23 99221 Initial hospital care None $ Initial hospital care None $ Initial hospital care None $ D SUBSEQUENT HOSPITAL CARE Subsequent hospital care None $ Subsequent hospital care None $ Subsequent hospital care None $ E OFFICE OR OTHER OUTPATIENT CONSULTATIONS NEW OR ESTABLISHED PATIENT Office consultation None $ Office consultation None $ Office consultation None $ Office consultation None $ Office consultation None $ F INITIAL INPATIENT CONSULTATIONS NEW OR ESTABLISHED PATIENT Initial inpatient consult None $ Initial inpatient consult None $ Initial inpatient consult None $ Initial inpatient consult None $ Initial inpatient consult None $ ##2010

24 19.13.G FOLLOW-UP INPATIENT CONSULTATIONS ESTABLISHED PATIENT Follow-up inpatient consult None $ Follow-up inpatient consult None $ Follow-up inpatient consult None $ H CONFIRMATORY CONSULTATIONS NEW OR ESTABLISHED PATIENT Confirmatory consultation None $ Confirmatory consultation None $ Confirmatory consultation None $ Confirmatory consultation None $ I EMERGENCY DEPARTMENT SERVICES NEW OR ESTABLISHED PATIENT Emergency depart visit None $ Emergency depart visit None $ Emergency depart visit None $ Emergency depart visit None $ Emergency depart visit None $ ##2010

25 19.13.J COMPREHENSIVE NURSING FACILITY ASSESSMENTS (NF) Follow-up inpatient consult None $ Follow-up inpatient consult None $ Follow-up inpatient consult None $ K NEW OR ESTABLISHED PATIENT Nursing fac care, subseq None $ Nursing fac care, subseq None $ Nursing fac care, subseq None $ L NEW PATIENT Rest home visit, new patient None $ Rest home visit, new patient None $ Rest home visit, new patient None $ M ESTABLISHED PATIENT Rest home visit, est pat None $ Rest home visit, est pat None $ Rest home visit, est pat None $ ##2010

26 19.13.N HOME SERVICES NEW PATIENT Home visit, new patient None $ Home visit, new patient None $ Home visit, new patient None $ O HOME SERVICES ESTABLISHED PATIENT Home visit, est patient None $ Home visit, est patient None $ Home visit, est patient None $20.00 END OF SECTION TOP OF PAGE 26-10##2010