Applies to:

All plans

Medicare plans follow Medicare coverage and billing rules

Medical policy

• Vision Care - 91538

Definition

Routine vision services include vision exams, services and hardware for non-medical related eye conditions. "Routine" vision services are defined by diagnosis and procedure codes, including near-sightedness and other common vision issues.

Routine vision services billing

See the Vision Care medical policy for a list of non-medical diagnosis codes billable with routine vision exams.

Refractions coverage

Refraction is always a routine vision benefit. If a member does not have vision coverage, refraction is not covered.

Refraction with vision screening: Generally not covered. Example: Section 6.1.A.1(d) of the HMO Certificate of Coverage states, "one vision screening during each contract year to determine vision loss. Vision screenings do not include refractions, which are tests to determine eyeglass prescription."

Refraction with medical diagnosis: Not covered.

When a member has routine vision benefits in addition to medical benefits, refraction is a covered service when billed with routine eye exams. Codes S0620 and S0621 include refraction. Some limits (e.g., 1 vision exam every 24 months) may apply.

Routine vision services billing

Priority Health pays routine vision claims according to a member's vision benefit. Members may have routine vision benefits under plans/riders separate from their health plan, or they may have limited routine vision benefits embedded in their health plan, such as Medicaid/Healthy Michigan Plan and some employer group plans and Medicare Advantage plans.

Routine vision benefits are available in the Member Inquiry tool.

Contact lens evaluation billing, 92310

Either an ophthalmologist or optometrist may bill 92310, contact lens evaluation.

Benefit language states that this service is included in the contact lens limitation. If contact lens benefit has not been met, all or a portion of the 92310 could be paid. However, once the patient has met their benefit limit for the contacts, 92310 will be denied as member liability.

• Bill 92310 only at the time of original contact lens prescription and fitting.
• When the provider performs a contact lens evaluation over and above the standard eye exam, bill either an S0620 or S0621 (standard eye exam) and the 92310.