Currentblue cross blue shield - michiganPolicy MAPPO 1007

Determination of refractive state

Defines when determination of refractive state (refraction) is covered and payable under Medicare Plus Blue PPO (Medicare Advantage) and specifies provider, billing, reimbursement, and member cost-sharing rules for covered circumstances.

Policy Summary

Payerblue cross blue shield - michigan

PolicyDetermination of refractive state

Policy CodePolicy MAPPO 1007

Change TypeAdministrative/content updates

Effective Date

Next Review Date

Key ActionObtain coverage determination from Blue Cross if unsure whether service is covered and verify benefits and member cost share via web‑DENIS or call 1-866-309-1719.

SourceLink

POLICY UPDATE CHANGES

Updated formatting, web links, conditions for payment, billing instructions; removed CAREN reference, added revision history section.

1Procedure code specified

2Diagnosis codes not payable

NonePayable location/frequency

07/23/2018Last review

AppliesMember cost share

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When Determination of Refractive State Is Covered

Coverage criteria for determination of refractive state

Determination of refractive state is covered only in defined situations and with specified billing rules.

ALL of the following

ONE of
- Provider must identify the member's refractive state to determine an injury, illness or disease.
- An ophthalmologist or an optometrist determines the refractive state for corrective lenses.
- The member's refractive state is determined as part of a surgical procedure.

ALL of the following

Service payable when performed by M.D., D.O., ophthalmologist or optometrist.

ALL of the following

When identifying refractive state to determine an injury, illness or disease: bill appropriate evaluation and management (E/M) codes (general ophthalmological services, office/outpatient services, consultations, or emergency department services) along with CPT 92015; both are payable.
When refractive state is determined for corrective lenses: a routine ophthalmological examination that includes the refraction must be billed; CPT 92015 cannot be reported as a separate procedure code.
When refractive state determination is part of a surgical procedure: bill the surgical procedure code; CPT 92015 is considered incidental or mutually exclusive and cannot be reported separately.

ALL of the following

Designated CPT code for determination of refractive state: 92015.
Diagnosis codes Z01.00 and Z01.01 are not payable when reported alone.

ALL of the following

Reimbursement: paid the lesser of the Medicare Advantage enhanced benefits fee schedule amount listed on the provider website or the provider charge (minus member cost share).
Providers should collect applicable member cost sharing at time of service when possible; providers may not use Advance Beneficiary Notices (ABNs) to waive prior coverage determinations and should obtain prior coverage determination from Blue Cross when the service is not clearly covered.

ALL of the following

Payable location and frequency: no restrictions.
For billing questions contact EDI Help Desk at 1-800-542-0945 or realtimesupport@bcbsm.com. For coverage determinations call 1-866-309-1719 or verify via web-DENIS.

Codes, Payment, and Billing Amounts

RefractionCPTCovered

92015

Determination of refractive state

Diagnosis restrictionsICD-10Not Covered

Z01.00	Encounter for examination of eyes and adnexa without abnormal findings
Z01.01	Encounter for examination of eyes and adnexa with abnormal findings

Maximum payment amount

Maximum payment sourceAmount listed in MA enhanced benefits fee schedule on Blue Cross provider website (bcbsm.com/providers/.../enhanced-benefits.html)

Payment calculationProvider will be paid the lesser of the MA enhanced benefits fee schedule amount or the provider's charge, minus the member's cost share.

Balance billingThis payment represents payment in full; providers are not allowed to bill the member for the difference between the allowed amount and the charge.

Provider Verification, Documentation, and Billing Actions

Prior Authorization

Obtain coverage determination and verify benefits/cost share

If there is any question about whether the determination of refractive state is covered, obtain a coverage determination from Blue Cross before providing the service. Verify member benefits and applicable cost sharing using web-DENIS or by calling 1-866-309-1719.

Seek coverage determination from Blue Cross if unsure whether the service is covered.
Verify benefits and the member’s cost share via web-DENIS or by phone at 1-866-309-1719.
Do not have members sign an Advance Beneficiary Notice (ABN) for Medicare Plus Blue noncovered services; obtain prior determination instead.

Key Definitions

Specification of lens characteristics (Determination of refractive state)

Definition (refractive state)Specification of lens type (monofocal, bifocal, other), lens power, axis, prism, absorptive factor, impact resistance and other factors necessary for obtaining glasses.

PurposeDetermination of refractive state is necessary for obtaining corrective lenses.

Included lens characteristicsLens type, lens power, axis, prism, absorptive factor, impact resistance and other relevant factors.

Medicare Advantage enhanced benefit (Medicare Plus Blue SM PPO)

Medicare Advantage enhanced benefitMedicare Plus Blue SM PPO may provide benefits beyond Original Medicare; Blue Cross determines scope, reimbursement methodology and maximum allowed payment amounts for determination of refractive state.

Relation to Original Medicare