65771 Radial keratotomy Not reimbursed
65782 Ocular surface reconstruction
65855 Trabeculoplasty by laser surgery, one or more sessions
66179 Aqueous shunt to extraocular equatorial plate reservoir, external approach; without graft
66184 Revision of aqueous shunt to extraocular equatorial plate reservoir; without graft
66761 Iridotomy, iredectomy by laser surgery
66990 Use of ophthalmic endoscope (add-on code intended to be reported with a specified list of other intraocular surgical procedures)
May only be billed and reimbursed with codes: 65820, 65875, 65920, 66985, 66986, 67036, 67039, 67040, 67041- 67043, 67107, 67108, 67110 and 67113 67101, 67105 Retinal repair 67141; 67145 Prophylaxis of retinal detachment without drainage, one or more sessions;
67101, 67105 Retinal repair
67141; 67145 Prophylaxis of retinal detachment without drainage, one or more sessions; cryotherapy, diathermy; photocoagulation
67208, 67210, 67218 Destruction of localized lesion of retina; one or more sessions; cryotherapy, diathermy; photocoagulation; radiation
67220 Destruction of localized lesion of choroids (e.g., choroidal neovascularization); photocoagulation (e.g., laser), one or more sessions 67221 Photodynamic therapy 67225 Photodynamic therapy, second eye, at single session 67227, 67228 Destruction of extensive or progressive retinopathy (e.g., diabetic retinopathy), one or more sessions; cryotheraphy, diathermy; photocoagulation 76514 Corneal pachymetry Reimbursement is limited to one test per member, per lifetime, for only the following diagnosis codes:
ICD-9 Covered Indications
364.22, 364.77, 365.00– 365.99, 371.20, 371.23, 371.57, 371.58
ICD-10 Covered Indications
92015 Determination of refraction Refraction services will not be reimbursed separately when performed on the same day as an eye exam or an E&M service.
92020 Gonioscopy
92071 Fitting of contact lens for treatment of ocular surface disease
Reimbursement is limited to one fitting per member, per lifetime for only the following diagnosis codes when submitted as the primary diagnosis:
ICD-9 Covered Indications
053.21, 054.42, 054.43, 279.52, 351.0-351.9, 370.33, 370.34, 370.35, 371.81, 375.15, 694.61, 695.13, 695.14, 695.15, 710.2, 743.45, 940.0-940.9
ICD-10 Covered Indications (continued)
92072 Fitting of contact lens for management of keratoconus, initial fitting
Reimbursement is limited to one fitting per member, per lifetime for only the following diagnosis codes when submitted as the primary diagnosis:
ICD-9 Covered Indications
371.60-371.62, 918.1
ICD-10 Covered Indications
92082, 92083 Visual field exam, intermediate and comprehensive
92100 Tonometry
92136 Ophthalmic biometry by partial coherence interferometry
92225, 92226 Ophthalmoscopy
92230, 92235 Fluorescein angioscopy
92240 Indocyanine-green angiograpny
92250 Fundus photography
92260 Opthalmodynamometry
92265 Needle oculoelectromyography
92270 Electro-oculography
92275 Electroretinography
92283 Extended color vision examination
92284 Dark adaptation examination
92285 External ocular photography
92286, 92287 Special anterior segment photography
92313 Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneoscleral lens Reimbursement is limited to only the following diagnosis codes:
ICD-9 Covered Indications
053.21, 054.42, 054.43, 279.52, 351.0-351.9, 370.33, 370.34, 370.35, 371.81, 375.15, 694.61, 695.13, 695.14, 695.15, 710.2, 743.45, 940.0-940.9
92499 Unlisted ophthalmological service or procedure Not reimbursed in addition to an E&M service when billed for preferential looking test.
99026, 99027 Hospital mandated physician on call services Not reimbursed
99173 Screening test of visual acuity Not reimbursed when billed with an E&M service
99177 Instrument-based ocular screening (e.g., photoscreening,automated-refraction), bilateral; with on-site analysis
Temporary or permanent lacrimal duct implants Provider liable — payment included in the allowance of another service
J0585 – J0588 Botulinum toxin type A or B Botulinum A and B toxins Medical Policy
J3490 Unclassified drugs NDC is required.
J7311 Fluocinolone Acetonide, intravitreal implant
Retisert. Clinical documentation that supports the covered condition is required. First time claim submissions can be submitted on paper with operative notes for consideration. If notes are not submitted, the claim will deny requesting notes. (continued)
V2500 Contact lens, PMMA , spherical, per lens Reimbursement is limited to only the following diagnosis codes:
ICD-9 Covered Indications
053.21, 054.42, 054.43, 279.52, 351.0-351.9, 370.33, 370.34, 370.35, 371.60-371.62, 371.81, 375.15, 694.61, 695.13, 695.14, 695.15, 710.2, 743.45, 918.1, 940.0-940.9
ICD-10 Covered Indications
V2501 Contact lens, PMMA , toric or prism ballast, per lens
V2502 Contact lens PMMA , bifocal, per lens
V2503 Contact lens, PMMA , color vision deficiency, per lens
V2510 Contact lens, gas permeable, spherical, per lens
V2511 Contact lens, gas permeable, toric, prism ballast, per lens
V2512 Contact lens, gas permeable, bifocal, per lens
V2520 Contact lens, hydrophilic, spherical, per lens
V2521 Contact lens, hydrophilic, toric, or prism ballast, per lens
V2522 Contact lens, hydrophilic, bifocal, per lens
V2523 Contact lens, hydrophilic, extended wear, per lens
V2530 Contact lens, scleral, gas impermeable, per lens
V2531 Contact lens, scleral, gas permeable, per lens
V2785 Processing, preserving and transporting corneal tissue
V2787 Astigmatism-correcting function of intraocular lens Not reimbursed
V2788 Presbyopia correcting function of intraocular lens
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