Ophthalmological Exam - With or Without Refraction

Important Note:

This page is for our commercial plans only for services prior to 1/1/2022.

HMSA has partnered with EyeMed, service date effective January 1, 2022. HMSA transitioned our current vision portfolio to a new vision benefit with EyeMed for the following line of business: Commercial, Akamai Advantage®, QUEST Integration, Fed 87. HMSA will continue to be the administrators for non-routine vision services through the members medical plan(s). For more information, please contact EyeMed at www.eyemedinfocus.com

Contact by phone:

For Providers 1-888-259-4344

Benefits for an ophthalmological exam or an ophthalmological exam with refraction will be applied according to the purpose of the visit, as recognized under the member’s medical or vision plan.

Vision Services

When a member requests vision-related services (e.g., the member wants a new prescription for glasses), the exam and refraction are eligible for coverage under the member’s vision rider.

If a minor medical condition (such as conjunctivitis) is detected during a routine vision exam and both an exam and refraction are performed, medical plan benefits cannot be applied because the primary intent of the exam was a routine vision exam.

No payment can be made for the exam and refraction if the member does not have a vision rider or has exhausted his or her vision rider benefits. If the member does not have a vision rider, the member is responsible for payment.

Vision visit examples:

Example 1

An HMSA member (an established patient) presents himself or herself at the physician’s office and says he or she needs a new prescription for glasses. The physician performs the following services:

92012

Ophthalmological exam for an established patient

92015

Determination of refractive state

Findings

The physician finds that the patient has astigmatism (ICD-9-CM: 367.20; ICD-10-CM: H52.203) and writes the patient a new prescription for corrective lenses. There are no other findings.

Claims filing and processing

The claim should be filed using the diagnosis for astigmatism (ICD-9-CM: 367.20; ICD-10-CM: H52.203). HMSA will apply the patient’s benefit for vision services. If the member does not have a vision rider, payment will not be made.

Example 2

An HMSA member (an established patient) presents himself or herself at the physician’s office and says he or she needs a new prescription for glasses. The physician performs the following services:

92012

Ophthalmological exam for an established patient

92015

Determination of refractive state

Findings

The physician finds that the patient has myopia (ICD-9-CM:367.1; ICD-10-CM: H52.13) and mild conjunctivitis (ICD-9-CM: 372.00; ICD-10-CM: H10.33). The physician writes the patient a new prescription for corrective lenses and gives the patient a sample tube of medicated ointment.

Claims filing and processing

The claim should be filed using a primary diagnosis for myopia (ICD-9-CM: 367.1; ICD-10-CM: H52.13). An optional secondary diagnosis of conjunctivitis (ICD-9-CM: 372.00; ICD-10-CM: H10.33) may also be added to the claim. HMSA will apply the patient’s benefit for vision services.

Because the purpose of the patient’s visit was primarily to obtain routine vision care services and the physician’s diagnosis of conjunctivitis was an incidental finding, if the member does not have a vision rider, payment will not be made.

Medical Care Services

When a member presents a complaint indicative of a major medical problem, such as seeing black spots with a final diagnosis of retinal detachment, both the exam and refraction are eligible for coverage under the member’s medical plan.

Medical visit examples:

Example 1

An HMSA member is referred to the ophthalmologist by his or her internist. The patient has been having constant headaches and the internist would like the ophthalmologist to check whether a refractive error might be responsible for the symptoms. The ophthalmologist performs the following services:

92004

Comprehensive ophthalmological exam for a new patient

92015

Determination of refractive state

Findings

The ophthalmologist is unable to conclude that a refractive error is causing the member’s headaches.

Claims filing and processing

The claim should be filed using a diagnosis of headache (ICD-9-CM: 784.0; ICD-10-CM: R51). HMSA will apply the patient’s benefit for medical services to both the examination and the refraction. The services will be paid under the patient’s medical plan because they were performed in an effort to diagnose the patient’s medical condition.

Example 2

An HMSA member (an established patient) comes into the physician's office for a periodic eye exam needed to monitor his or her diabetic retinopathy. The physician performs the following services:

92012

Ophthalmological exam for an established patient

92015

Determination of refractive state

Findings

The physician finds little change in the patient’s condition.

Claims filing and processing

The claim should be filed using a diagnosis of diabetic retinopathy (ICD-9-CM codes 250.00 and 362.01; ICD-10-CM codes E11.9 and E08.319). HMSA will apply the patient’s benefit for medical services to both the examination and the refraction. The services will be paid under the patient’s medical plan because they were performed to monitor the patient’s medical condition.

Diagnosis Codes

Diagnosis codes are used by HMSA to determine whether the visit should be processed under the member’s medical plan or vision rider benefits. The following charts illustrate HMSA’s use of diagnosis codes relative to the processing of claims for ophthalmological exams with or without a refraction.

Coding

For more information about specific diagnosis code designations see:

• Ophthalmological Diagnosis Codes - Minor
• Ophthalmological Diagnosis Codes - Major
• Ophthalmological Diagnosis Codes - Refractive

Important

When a routine vision examination and refraction are performed for the same patient on the same day, the services must be listed on the same claim form. This will ensure that the member’s vision rider benefits are correctly applied.

Revision History