Important Note:
This page is for our commercial plans only for services prior to 1/1/2022.
The diagnoses within these articles are for Dates of Services prior to 2022. For dates of services on and after January 1, 2022, please go to www.eyemedinfocus.com.
When an ophthalmological exam, or an ophthalmological exam and refraction, is performed to diagnose or treat an HMSA member for routine refractive errors, the member’s vision rider benefits for vision services will be applied.
If the member does not have a vision rider or has exhausted his or her vision rider benefits for the year, the member will be responsible for payment. Services performed for routine refractive conditions are not covered under the member’s medical plan.
Listed below are diagnosis codes that HMSA considers routine refractive diagnoses.
| ICD-9-CM code | Description | ICD-10-CM Code | Description |
|---|---|---|---|
| V41.0 | Problems with sight |
Z97.3 H54.7 |
Presence of spectacles and contact lenses Unspecified visual loss |
| V41.1 | Other eye problems | N/A | N/A |
| V72.0 | Examination of eyes and vision |
Z01.00 Z01.01 Z01.020 Z01.021 |
Encounter for examination of eyes and vision without abnormal findings Encounter for examination of eyes and vision with abnormal findings Encounter for examination of eyes and vision following failed vision screening without abnormal finding Encounter for examination of eyes and vision following failed vision screening with abnormal findings |
| V80.2 | Special screening for neurological, eye and ear diseases; other eye conditions | Z13.5 | Encounter for screening for eye and ear disorders |
| 367.0 | Hypermetropia |
H52.01 H52.02 H52.03 |
Hypermetropia, right eye Hypermetropia, left eye Hypermetropia, bilateral |
| 367.1 | Myopia |
H52.11 H52.12 H52.13 |
Myopia, right eye Myopia, left eye Myopia, bilateral |
| 367.20 - 367.22 | Astigmatism |
H52.201 H52.202 H52.203 H52.211 H52.212 H52.213 H52.221 H52.222 H52.223 |
Unspecified astigmatism, right eye Unspecified astigmatism, left eye Unspecified astigmatism, bilateral Irregular astigmatism, right eye Irregular astigmatism, left eye Irregular astigmatism, bilateral Regular astigmatism, right eye Regular astigmatism, left eye Regular astigmatism, bilateral |
| 367.31 | Anisometropia | H52.31 | Anisometropia |
| 367.32 | Aniseikonia | H52.32 | Aniseikonia |
| 367.4 | Presbyopia | H52.4 | Presbyopia |
| 367.81 - 367.89 | Other disorders of refraction and accommodation | H52.6 | Other disorders of refraction |
| 367.9 | Unspecified disorder of refraction and accommodation | H52.7 | Unspecified disorder of refraction |
| 368.9 | Unspecified visual disturbance | H53.9 | Unspecified visual disturbance |
| 369.00 - 369.08 | Profound impairment, both eyes |
H54.0 H54.10 |
Blindness, both eyes Blindness, one eye, low vision other eye, unspecified eyes |
| 369.10 - 369.18 | Moderate or severe impairment, better eye, profound impairment lesser eye |
H54.10 H54.11 H54.12 |
Blindness, one eye, low vision other eye, unspecified eyes Blindness, right eye, low vision left eye Blindness, left eye, low vision right eye |
| 369.20 - 369.25 | Moderate or severe impairment, both eyes |
H54.10 H54.2 |
Blindness, one eye, low vision other eye, unspecified eyes Low vision, both eyes |
| 369.3 | Unqualified visual loss, both eyes | H54.3 | Unqualified visual loss, both eyes |
| 369.4 | Legal blindness, as defined in USA | H54.8 | Legal blindness, as defined in USA |
| 369.60 - 369.69 | Profound impairment, one eye |
H54.40 H54.41 H54.42 |
Blindness, one eye, unspecified eye Blindness, right eye, normal vision left eye Blindness, left eye, normal vision right eye |
| 369.70 - 369.76 | Moderate to severe impairment, one eye |
H54.40 H54.50 H54.51 H54.52 |
Blindness, one eye, unspecified eye Low vision, one eye, unspecified eye Low vision, right eye, normal vision left eye Low vision, both eyes |
| 369.8 | Unqualified visual loss, one eye |
H54.60 H54.61 H54.62 |
Unqualified visual loss, one eye, unspecified Unqualified visual loss, right eye, normal vision left eye Unqualified visual loss, left eye, normal vision right eye |
| 369.9 | Unspecified visual loss | H54.7 | Unspecified visual loss |
Information
For more information see Ophthalmological Exam - With or Without Refraction.
Revision History
| Date | Nature of Revision |
|---|---|
| 08/03/2026 | Migrated to new platform. |