CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Visual Acuity and Instrument-Based Ocular Screening Coverage

Defines coverage and reimbursement rules for visual acuity testing and instrument-based ocular screening (photoscreening/automated refraction) for commercial products, specifying age-based reimbursement and filing guidance. Affects providers submitting claims to Blue Cross Blue Shield - Rhode Island for pediatric and other patient eye screening services.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyVisual Acuity and Instrument-Based Ocular Screening Coverage

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionVerify member-specific benefits and eligibility via the subscriber agreement or member certificate before submitting claims.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

99173/99174/99177primary screening CPT codes referenced

0-5 yrsages for separate reimbursement

2/yrfreq: 0-11 months

1/yrfreq: 1-5 yrs

Not separatereimbursement >5 yrs

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Coverage Criteria and Billing Rules

Age-based coverage criteria

Coverage and reimbursement rules by age

Ages 3-5 preventive visit visual acuity: 99173 is covered and separately reimbursable when performed in conjunction with a preventive medicine service (99382, 99383, 99392, 99393) for patients aged 3-5 years.age 3-5

Performed with preventive medicine service

Instrument-based ocular screening for children 0-11 months: 99174 and 99177 are covered and separately reimbursed up to twice per year for children ages 0-11 months.age 0-11 months; frequency: 2/year

Remote (99174) or onsite (99177) analysis acceptable

Instrument-based ocular screening for children 1-5 years: 99174 and 99177 are covered and separately reimbursed once per year for children ages 1-5 years.age 1-5 years; frequency: 1/year

Patients greater than age 5: For children older than age 5, the screening codes (99173, 99174, 99177) are covered but are not separately reimbursed because visual acuity screening is considered integral to E/M or ophthalmology services.age >5

Do not file 99173 on same day as 99174/99177

Instrument-based ocular screening codes 99174 and 99177 should not be filed on the same day as the visual acuity screening code 99173. This guidance applies regardless of age and is intended to prevent duplicate filing for overlapping screening services.

No specific medical necessity criteria are applicable to this policy. The policy states that there are no medical criteria defined for these services.

Coding and Reimbursement

Covered CPT Codes (visual acuity)CPTCovered

99173

Screening Test of Visual Acuity, Quantitative, Bilateral

Covered CPT Codes (instrument-based ocular screening)CPTCovered

99174	Instrument-based ocular screening (e.g., photoscreening, automated-refraction), bilateral; with remote analysis and report
99177	Instrument-based ocular screening (photoscreening, automated-refraction), bilateral; with onsite analysis

Related Ophthalmology/E&M Codes (diagnostic vs screening context)mixed

92002	Ophthalmological services (examples listed in background)
92004	Ophthalmological services
92012	Ophthalmological services
92014	Ophthalmological services
92081	Visual field examination
92082	Visual field examination
92083	Visual field examination
99201-99215	Evaluation and Management codes

Provider Actions, Filing Guidance, and Risks

Prior Authorization

Prior authorization is not required for visual acuity or instrument-based ocular screening services.

Billing Rule

Provider billing note / filing guidance

Visual acuity screening (CPT 99173) is separately reimbursable only when performed with a preventive medicine service (CPT 99382, 99383, 99392, 99393) for patients aged 3–5 years. For other ages, 99173 is considered integral to an E/M or preventive visit and is not separately reimbursed. Instrument-based ocular screening (CPT 99174, 99177) is covered and separately reimbursable for children 0–11 months (twice per year) and 1–5 years (once per year). Do not file 99174 or 99177 on the same date of service as 99173.

Affected codes: 99173, 99174, 99177
Preventive medicine service codes: 99382, 99383, 99392, 99393

Definitions

Visual acuity testing

DefinitionMeasurement of the sharpness or clarity of vision (ability to distinguish letters or images at a fixed distance), typically using a Snellen chart.

When considered screening vs diagnosticWhen measured as part of a pediatric preventive (well‑child) visit it is a screening test; when measured as part of a general ophthalmological or E/M service it is diagnostic and should be reported with ophthalmology (92002–92014, 92081–92083) or E/M (99201–99215) codes.

Typical settingCommonly performed during pediatric preventive visits (well‑child exams).

Associated CPT code99173 — Screening test of visual acuity, quantitative, bilateral (covered for ages indicated in policy).

Notes on reportingDo not file 99173 on the same day as instrument‑based ocular screening codes (99174/99177) per policy guidance for same‑day filing restrictions.

Background

Visual acuity testing measures the clarity or sharpness of vision and is commonly performed during pediatric preventive visits, often using a Snellen chart or equivalent method. Instrument-based ocular screening (photoscreening/automated refraction) uses photorefraction techniques — images captured in a darkened environment analyzed either onsite or remotely — to assess refractive state, fixation pattern, and possible strabismus, with results typically reported as pass, fail, or repeat. The policy distinguishes the two modalities for coverage and reimbursement purposes and provides age-based rules for separate reimbursement.

For children ages 0–11 months, instrument-based screening (99174, 99177) is covered and separately reimbursed up to twice per year. For children ages 1–5 years, these codes are covered and separately reimbursed once per year. Visual acuity testing (99173) is covered and separately reimbursable when performed with a preventive medicine service for patients aged 3–5 years; for patients older than 5 years these screening services are considered integral to E/M or ophthalmology services and are not separately reimbursed.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyVisual Acuity and Instrument-Based Ocular Screening Coverage

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionVerify member-specific benefits and eligibility via the subscriber agreement or member certificate before submitting claims.

SourceLink

On This Page

Frequency limits: 99174/99177 — 0–11 months: twice/year; 1–5 years: once/year

Note

Member-specific benefits verification

Verify the member's specific benefits and eligibility prior to providing services. Coverage and reimbursement can vary by group/contract; the member’s Evidence of Coverage or Subscriber Agreement governs benefits. For member-specific benefit questions, contact the BCBSRI provider call center.

Denial Risk

Age-based reimbursement denial risk

Age-based reimbursement rules apply: 99173 is separately reimbursable only for ages 3–5 when billed with a preventive medicine code; for patients >5 years, visual acuity testing is not separately reimbursable. Instrument-based screening (99174, 99177) is separately reimbursable only for children under age 6 per the stated frequency limits and is not separately reimbursable for older children and adults. Claims billed outside these age-based rules risk denial.

99173 separately reimbursable only when billed with preventive medicine (ages 3–5)
99174/99177 covered and separately reimbursable for 0–11 months (twice/year) and 1–5 years (once/year); >5 years — not separately reimbursable

Instrument-based ocular screening (photoscreening/automated refraction)

DefinitionInstrument‑based ocular screening (photoscreening/automated refraction): photorefraction-based screening where images taken in a darkened room are analyzed (onsite or remote) for refractive state, fixation pattern, and presence of strabismus; results graded as pass, fail, or repeat.

Covered CPT codes & descriptions99174 — Instrument-based ocular screening, bilateral; with remote analysis and report; 99177 — Instrument-based ocular screening, bilateral; with onsite analysis (both covered).

Age‑based frequency rulesAges 0–11 months: 99174/99177 covered and separately reimbursed up to twice per year; Ages 1–5 years: covered and separately reimbursed once per year.

Same‑day filing restrictionInstrument‑based screening (99174/99177) should not be filed on the same day as visual acuity screening (99173).

Analysis locationRemote analysis (99174) or onsite analysis (99177) are both acceptable per the policy.