This section describes program information and billing policies for ophthalmology services.
Correct Claim Form Ophthalmological services can be billed on either a CMS-1500 or
UB-04 (outpatient providers) claim form. The following
ophthalmological and eye appliance procedure codes, however, must
be billed only on the CMS-1500:
CPT-4 codes: 68761, 92002 – 92060, 92070 – 92284,
92310 – 92353, 92370, 92371 and 92499
HCPCS codes: S0500, S0512, S0514, S0516, V2020 – V2499,
V2500, V2501, V2510, V2511, V2513 – V2521, V2523, V2599,
V2600 – V2615, V2623 – V2629, V2702 – V2718, V2744 – V2755,
V2760 – V2770, V2781 – V2784 and V2799
Modifiers Ophthalmological services and eye appliances (frames, lenses,
contact lens, etc.) must be billed with the appropriate modifier(s).
Vision care modifiers are listed in the Modifiers for Vision Care
Services section of the Part 2 Vision Care manual.
2 – Ophthalmology October 2009
Unilateral and Bilateral The CPT-4 90000 series of codes for eye procedures are considered bilateral services. Therefore, a code should be billed only once, regardless of whether one or both eyes were involved. However, in the case of eye surgeries, this does not apply, and the appropriate code should be used to specify whether the procedure was unilateral or bilateral.
The following codes may be billed as unilateral or bilateral services.
CPT-4 Code Description
92132 Scanning computerized ophthalmic diagnostic
imaging, anterior segment, with interpretation
92133 Scanning computerized ophthalmic diagnostic
imaging, posterior segment, with
interpretation and report; optic nerve
92225 Ophthalmoscopy, extended, with retinal
drawing [eg, for retinal detachment,
melanoma], with interpretation and report;
92227 Remote imaging for detection of retinal
disease (eg, retinopathy in a patient with
diabetes) with analysis and report
* 92228 Remote imaging for monitoring and
maintenance of active retinal disease (eg,
diabetic retinopathy) with physician review,
interpretation and report
92230 Fluorescein angiography with interpretation
92235 Fluorescein angiography [includes multiframe
imaging] with interpretation and report
When performed as a unilateral procedure these procedures must be billed with a quantity of “1” and either modifier LT (left side) or RT (right side) to indicate the side of the body on which the procedure is performed.
When performed as a bilateral procedure, claims must be billed on a single line using modifier 50 (bilateral procedure) with a quantity of “2.”
* Note: This code is split-billable and must be billed with the
appropriate modifiers (26, TC or ZS)
2 – Ophthalmology March 2012
Ophthalmic CPT-4 code 92135 (scanning computerized ophthalmic diagnostic Diagnostic Imaging: imaging [eg, scanning laser] with interpretation and report, unilateral) Billing Restrictions is not reimbursable when billed for the same recipient, by the same
rendering provider, for the same date of service as the following
CPT-4 Code Description
76512 B-scan (with or without superimposed
92225 Ophthalmoscopy, extended, with retinal drawing
(eg, for retinal detachment, melanoma), with
interpretation and report; initial
92250 Fundus photography with interpretation and report
ICD-9-CM Diagnosis Refer to the Ophthalmology: Diagnosis Codes section in this manual
Code Requirements for ICD-9-CM diagnosis codes that must be billed in conjunction with
Corneal Pachymetry CPT-4 code 76514 is payable only once-in-a-lifetime when billed with
the glaucoma-related diagnosis codes indicated in the Professional
Services: Diagnosis Code section in this manual. Refer to the
Radiology: Diagnosis Ultrasound section for the ICD-9-CM diagnosis
codes to bill in conjunction with code 76514 for payment, in the
appropriate Part 2 manual.
2 – Ophthalmology January 2009
Computerized Computerized corneal topography (CPT-4 code 92025) is Corneal Topography reimbursable to optometrists within their scope of practice. It requires
When billing for code 92025, providers must document in the
Remarks field (Box 80)/Reserved for Local Use field (Box 19) of the
claim or on an attachment that the service was performed according
to one of the following criteria:
; Pre- or post-operatively for corneal transplant (codes 65710,
65730, 65750, 65755 and 65756)
; Pre- or post-operatively prior to cataract surgery due to
irregular corneal curvature or irregular astigmatism
; In the treatment of irregular astigmatism as a result of corneal
disease or trauma
; To assist in the fitting of contact lenses for patients with
corneal disease or trauma (ICD-9-CM diagnosis codes 371 –
; To assist in defining further treatment
This procedure is not covered under the following conditions:
; When performed pre- or post-operatively for non-Medi-Cal
covered refractive surgery procedures such as codes 65760
(kerato mileusis), 65765 (keratophakia), 65767
(epikeratoplasty), 65771 (radial keratotomy), 65772 (corneal
relaxing incision) and 65775 (corneal wedge resection)
; When performed for routine screening purposes in the absence
of associated signs, symptoms, illness or injury
Billing Requirements CPT-4 code 92025 must be billed with the appropriate modifiers
(26, 99, TC or ZS).
2 – Ophthalmology September 2009
Ranibizumab (Lucentis?) Ranibizumab (HCPCS code J2778) is reimbursable with an approved Treatment Authorization Request (TAR) for the treatment of exudative
senile macular degeneration (ICD-9-CM diagnosis code 362.52) or macular edema following retinal vein occlusion (primary ICD-9-CM code 362.83) with a secondary ICD-9-CM code of either 362.35 (central retinal vein occlusion) or 362.36 (venous tributary [branch] occlusion).
Note: When a TAR is requested for the treatment of exudative senile
macular degeneration, providers must include medical
justification for the use of ranibizumab over bevacizumab (e.g.,
potential higher relative risks and adverse effects, etc.).
Reimbursement is limited to 12 injections per eye, per year. When 12 injections are requested for the treatment of exudative senile macular degeneration, providers must indicate the reason ranibizumab cannot be given as needed with monthly evaluation. Appropriate site modifiers for this code are LT, RT or 50 if bilateral. Code J2778 must be billed on the same claim as CPT-4 code 67028 (intravitreal injection of a pharmacologic agent).
?) Bevacizumub, 10 mg (HCPCS code J9035), is reimbursable for the Bevacizumab (Avastin
treatment of exudative senile macular degeneration (ICD-9-CM code 362.52) by intravitreal injections.
In addition to billing with ICD-9-CM code 362.52, providers must submit the following documentation in the Reserved for Local Use
field (Box 19) of the claim or on a separate attachment:
; Notation of the eye being treated, right, left or both.
; Indication for treatment; choroidal neovascularization (CNV), or
macular edema, or pigment epithelial detachment secondary to
wet age-related macular degeneration (AMD).
; History of progressive visual loss or worsening of anatomic
appearance as determined by fluorescein angiography, optical
coherence tomography (COT) or scanning computerized
ophthalmic diagnostic imaging
Treatments are limited to 12 intravitreal injections of bevacizumab per year per eye.
HCPCS code J9035 descriptor denotes 10 mg of bevacizumab. Current literature indicates anticipated dosage is 1.25 mg or less when used off-label in the eye to treat exudative senile macular degeneration. Providers may bill for the quantity that is equal to the amount given to the patient plus the amount wasted. However, Medi-Cal will pay no more than one unit (10 mg) per patient, per date of service when bevacizumab is used for the treatment of exudative senile macular degeneration. This limitation does not apply to FDA-approved indications of bevacizumab.
2 – Ophthalmology June 2011
“By Report” In some situations it may be necessary to bill “By Report” – include a
Procedures brief report that justifies the procedure.
The following CPT-4 codes require medical justification. Claims for
these procedures will suspend for medical review and/or manual
pricing. Justification includes, but is not limited to: the patient’s
diagnosis and associated symptoms, a short explanation of why the
visit was necessary, a summary of services performed and the
outcome and a statement of the treatment plan that indicates whether
a referral was made.
CPT-4 Code Description
65210 Removal of foreign body, external eye;
67938 Removal of embedded foreign body, eyelid
68761 Closure of the lacrimal punctum
68801 Dilation of the lacrimal punctum
92018 Ophthalmological examination and evaluation,
under general anesthesia, with or without
manipulation of globe for passive range of
motion or other manipulation to facilitate
diagnostic examination; complete
92025 Computerized corneal topography, unilateral or
bilateral, with interpretation and report
92100 Serial tonometry
92225 Extended ophthalmoscopy
92250 Fundus photography with interpretation and
92310 – 92312 Contact lens evaluations
92499 Unlisted ophthalmological service or procedure
2 – Ophthalmology September 2009
Routine Claims by either an ophthalmologist or optometrist for routine
Examinations comprehensive eye examinations (CPT-4 codes 92004 [new patient]
and 92014 [established patient]) are covered once every two years for
recipients of any age.
Determination of When performed, determination of refractive state (CPT-4 code Refractive State 92015) must be separately reported when billed in conjunction with
CPT-4 code 92004 or 92014.
Code 92015 is considered typical postoperative follow-up care
included in the surgical package for cataract extraction surgeries.
Therefore, this service is not reimbursable when billed in conjunction
with or within the 90-day post follow-up period of CPT-4 codes 66840,
66850, 66852, 66920, 66930, 66940 and 66982 – 66985.
Tonometry Tonometry services are included in an eye examination and should
not be billed as a separate procedure.
Note: This is a one-time measurement and not serial tonometry.
Diagnostic Drugs The use of topically applied diagnostic drugs (cycloplegic, mydriatic or
anesthetic topical pharmaceutical agents) is included in the
reimbursement of ophthalmological procedures.
2 – Ophthalmology October 2008
Interim Examinations A second eye examination with refraction within 24 months is covered
only when a sign or symptom indicates a need for this service.
Claims billed with CPT-4 codes 92004 and 92014 must include the
appropriate ICD-9-CM code that justifies the examination in (Box 67)
of the UB-04 claim form or Nature of Illness or Injury field (Box 21) of
the CMS-1500 claim. This policy applies whether the claim is
submitted by the provider of the prior examination or by a different
provider. Refer to the Professional Services: Diagnosis Codes
section in the Part 2 Vision Care manual for a list of required
ICD-9-CM diagnosis codes when billing for interim comprehensive
eye examinations within the 24-month benefit period.
E&M Codes Not Evaluation and Management (E&M) visit codes (CPT-4 codes
Reimbursable With 99201 – 99215) should not be billed with eye examination codes Eye Examination (CPT-4 codes 92002, 92004, 92012 and 92014) by the same provider,
Services for the same recipient and date of service. Reimbursement for
duplicate services will be reduced or denied.
2 – Ophthalmology January 2008
Medicare-Covered Services Eye examinations for Medicare/Medi-Cal-eligible recipients must be
billed to Medicare prior to billing Medi-Cal for the following claims:
; Examinations performed in conjunction with eye disease (such
as glaucoma or cataract) or eye injury
; Interim examinations for recipients with a sign or symptom that
justifies the need for an examination (providers must include
the principal ICD-9-CM diagnosis code on the claim)
Medicare Non-Covered Routine examinations for the purpose of prescribing, fitting or
changing eyeglasses, as well as eye refractions, are not covered by
Medicare. Eye examination claims (CPT-4 codes 92002, 92004,
92012 and 92014) for Medicare/Medi-Cal-eligible recipients with only
diagnoses for disorders, refraction, accommodation and color vision
deficiencies may be billed directly to Medi-Cal. The recipient’s
primary ICD-9-CM diagnosis code must be entered in the Principal
Diagnosis Code field (Box 67) of the UB-04 claim form or Diagnosis
or Nature of Illness or Injury field (Box 21) of the CMS-1500 claim
Determination of refractive state (CPT-4 code 92015) is not covered
by Medicare and may be billed directly to Medi-Cal.
Refer to the Medicare Non-Covered Services: CPT-4 Codes section in
this manual for a list of ICD-9-CM diagnosis codes that may be
submitted directly to Medi-Cal in conjunction with CPT-4 codes 92002,
92004, 92012 and 92014.
Hard Copy Billing Claims that do not automatically cross over electronically from Crossover Claims Medicare carriers must be hard copy billed to the the Department of
Healthcare Services (DHCS) Fiscal Intermediary (FI) Crossover Unit
on a CMS-1500 claim form. Refer to the Medicare/Medi-Cal
Crossover Claims: Vision Care section in the appropriate Part 2
manual for detailed crossover billing information.
Providers must attach a copy of the Explanation of Medicare Benefits
(EOMB)/Medicare Remittance Notice (MRN) to all crossover claims.
Refractive services (CPT-4 code 92015) may be billed directly to
2 – Ophthalmology November 2009
Contact Lenses Claims billed with CPT-4 codes 92310 (prescription of optical and
physical characteristics of and fitting of contact lenses, with medical
supervision of adaptation; corneal lens, both eyes, except for
aphakia), 92311 (…corneal lens for aphakia, one eye) and 92312
(…corneal lens for aphakia, both eyes) require authorization (a
Treatment Authorization Request) from the Department of Health
Care Services (DHCS) Vision Care Policy Unit (VCPU). Refer to the
Contact Lenses and TAR Completion for Vision Care sections in the
Part 2 Vision Care manual for policy and billing instructions.
Modifiers 22 and SC Providers can only use modifiers 22 and SC when billing for CPT-4
codes 92310 – 92312.
Required Information The following information is required in the Medical Justification field
of the 50-3 Treatment Authorization Request (TAR) form or on a
separate attachment. For additional information about the
authorization process, refer to the TAR Completion for Vision Care
section in the Part 2 Vision Care manual.
; Valid diagnosis or condition that precludes the satisfactory
wearing of conventional eyeglasses, including documentation
of clinical data when possible
; Best corrected visual acuities through eyeglasses and contact
; Identification of the contact lens to be used by trade or
manufacturer’s name, base curve, diameter and power
; For a diagnosis of aniseikonia (ICD-9-CM code 367.32), a
statement that indicates why eyeglasses cannot be used and
supporting clinical data. (Anisometropia greater than three
diopters, coupled with the presence of symptoms commonly
associated with aniseikonia can qualify contact lenses for
authorization. Where a smaller degree of anisometropia is
present, detailed justification is required.)
; For conditions where contact lenses are the only option, a
statement of the chronic pathology or deformity of the nose,
skin or ears that precludes the wearing of conventional
; If extended wear contact lenses are prescribed, justification of
why conventional, disposable or plan replacement extended
wear lenses rather than daily wear lenses are necessary.
(When infirmity is a pertinent factor in the decision, a
statement that demonstrates the immediate availability of
someone to assist the recipient in lens insertion, centering and
removal is required.)
; A statement that indicates whether a recipient has worn contact
lenses in the past
2 – Ophthalmology January 2008