Tuesday, July 10, 2012

Usage of DX V72.0 Optometry eye exams

Active Duty Service Members (ADSMs)
TRICARE Prime ADSMs must receive all vision care at a military treatment facility (MTF) unless specifically referred to a network provider (or non- network provider if a network provider is not available).

TRICARE Prime Remote ADSMs may obtain comprehensive eye examinations from network providers as needed to maintain fitness- for-duty status without authorization.

Active Duty Family Members (ADFMs)
One routine eye exam to check for vision and diseases per calendar year, regardless of TRICARE program option.

Medically necessary care for injuries to the eye is covered. Retired Service Members and Their Dependents (includes all beneficiaries other than ADSMs and ADFMs)

If enrolled in TRICARE Prime, one routine eye exam to check for vision and diseases every two years (except for diabetic patients, see “Diabetic Patients” in this figure).

If using TRICARE Standard and TRICARE Extra or TRICARE For Life, no coverage (except for well-child benefit and diabetic patients, see “Well- Child Benefit” and “Diabetic Patients” in this figure).

Medically necessary care for injuries to the eye is covered. Well-Child Benefit

For all TRICARE-eligible infants and children up to age 6:

Infants may receive one eye and vision screening1 during routine exams at birth and at approximately 6 months under the well-child benefit.

Use V20.2 for eye exams under the well-child benefit.

Children may receive two pediatric routine eye exams2 between the ages of 3 and 6 under the well-child benefit (use V20.2). 

Diabetic Patients
Diabetic patients at any age are allowed one routine eye examination each calendar year.

Note: For TRICARE Prime enrollees, a primary care manager (PCM) or TriWest referral is not needed, but TRICARE Prime beneficiaries must see an MTF or network optometrist or ophthalmologist. The V
code can be used for the annual exam; however, if a medical condition is identified, use medical diagnosis Current Procedural Terminology (CPT®) codes.

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