CurrentBlue Cross Blue Shield - MichiganPolicy N/A

Routine ophthalmological exam including refraction — Coverage Criteria

This policy governs coverage, payment, and billing rules for routine ophthalmological examinations including refraction as an enhanced Medicare Advantage benefit for University of Michigan Medicare Plus Blue Group PPO members.

Policy Summary

PayerBlue Cross Blue Shield - Michigan

PolicyRoutine ophthalmological exam including refraction — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionObtain a coverage determination from Medicare Plus Blue when there is uncertainty about whether the service is covered before providing the service.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1/yrfrequency limit

S0620,S0621,92002-92014covered CPT/HCPCS

Nonediagnosis requirement

All agesage applicability

01/01/2026policy effective

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Coverage Criteria

Routine ophthalmological exam coverage criteria

Covered when ALL of the following conditions are met

Benefit applicability: Member is enrolled in University of Michigan Medicare Plus Blue Group PPO plan that selected this enhanced benefit

Policy is an enhanced Medicare Advantage benefit that may remove Original Medicare diagnosis restrictions

Provider and place of service: Provided by M.D., D.O., ophthalmologist or optometrist at any payable location

Eligible provider types listed without location restrictions

Frequency: One routine eye exam including refraction per member per calendar year1 per calendar year

Applies to all ages; no age restrictions

CPT/HCPCS codes: Service billed with one of the listed CPT/HCPCS codes: S0620, S0621, 92002, 92004, 92012, or 92014

Use codes as listed in policy

If a member elects to receive a noncovered service, the member is responsible for the entire charge for that service. Providers may only collect the Medicare Plus Blue cost sharing amounts that apply and should collect applicable cost sharing at the time of service when possible. Providers may not have members sign an Advance Beneficiary Notice of Noncoverage (ABN) to accept financial responsibility for noncovered items. If there is any question about coverage, obtain a coverage determination from Medicare Plus Blue before providing the service.

Original Medicare does not cover routine ophthalmological exam including refraction; ophthalmological services under Original Medicare are subject to diagnosis restrictions. This policy applies to Medicare Advantage members in participating group plans as an enhanced benefit and therefore may provide coverage for the routine exam without the diagnosis restrictions that apply under Original Medicare. If coverage is uncertain for a particular service, providers should request a coverage determination from Medicare Plus Blue before performing the service.

Coding and Frequency

Covered CPT/HCPCS CodesmixedCovered

S0620	Routine ophthalmological examination including refraction; new patient
S0621	Routine ophthalmological examination including refraction; established patient
92002	Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; intermediate, new patient
92004	Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; comprehensive, new patient, 1 or more visits
92012	Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established patient
92014	Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive, established patient, 1 or more visits

ICD-10 CodesICD-10

No codes listed

inv-06: Frequency limit — One routine eye exam per member per calendar year

Frequency limitOne routine eye exam per member per calendar year

Applies toAll ages (no age restrictions)

Provider typesM.D., D.O., ophthalmologist or optometrist may provide the service

Place of serviceNo payable location restrictions

Provider Actions and Billing

Prior Authorization

Coverage determination required

If there is any question about whether an item or service is covered, obtain a coverage determination from Medicare Plus Blue before providing the service.

If coverage is uncertain, contact Medicare Plus Blue for a coverage determination prior to delivering the service.

Note

(No additional provider action specified.)

Documentation Required

Claims documentation and verification

Report CPT/HCPCS and diagnosis codes to the highest level of specificity, include your NPI on all claims, and verify member benefits and cost sharing via the Medicare Plus Blue provider portal (Availity) or by calling 1-866-309-1719.

Background

A routine ophthalmological exam including refraction evaluates visual acuity and the eyes' ability to focus and includes assessment of peripheral and color vision, external and internal eye structures, tear ducts, and relevant cranial nerve function. The exam determines refractive status to identify needs for corrective lenses and may include both intermediate and comprehensive evaluation components as described by the listed CPT/HCPCS codes.

Definitions

inv-12: Definition of 'Routine ophthalmological exam including refraction' — what the exam evaluates

DefinitionRoutine ophthalmological exam including refraction — an examination to determine the ability of the eyes to focus; evaluates outer and internal eye structures, tear ducts, cranial nerves, and tests visual acuity, peripheral vision, and color vision.

Exam componentsAssessment of visual acuity, peripheral vision, and color vision

Structural evaluationEvaluation of external (outer) eye structures, tear ducts, and internal eye structures

Neurologic checksAssessment of relevant cranial nerve function

Revision History

2025-11-25approval

Policy approved by Medicare Advantage Medical Director (approval recorded).

2026-01-01effective_dateLatest

Policy became effective as an enhanced Medicare Advantage benefit for University of Michigan Medicare Plus Blue Group PPO members (transitioned to new template).