CurrentMass General Brigham Health PlanPolicy N/A

Vision services reimbursement (eye exams and refractions)

Governs reimbursement of routine and medically necessary ophthalmology and optometry services for Mass General Brigham Health Plan members, including limits on separate reimbursement for refraction and coverage related to cataract and keratoconus. Affects contracted ophthalmologists and optometrists and applies across places of service.

Policy Summary

PayerMass General Brigham Health Plan

PolicyVision services reimbursement (eye exams and refractions)

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionObtain referral for non-routine eye care and secure prior authorization from the plan for non-contracted providers and certain eye-related procedures.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

90 daystimeframe to file claims

92002-92014E/M service codes referenced

92015 post-cataract/keratoconusrefraction reimbursement exception

Prior authorizationprior auth required

SpecteraCommonwealth Care manager

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Coverage Criteria for Vision Services

Coverage criteria — routine and non-routine vision services, refraction, fittings, and eyewear

Covered when the following conditions are met:

Routine and medically necessary vision services provided by contracted ophthalmologists and optometrists are reimbursed by Mass General Brigham Health Plan.

Refraction (CPT 92015) is not reimbursed separately except when performed in relation to post-cataract surgery or for treatment of keratoconus.

When reimbursed, 92015 must be submitted with an appropriate ICD-10 (e.g., H28.xx or H18.609/H18.619/H18.629).

ALL of the following

CPT 92072 (fitting for management of keratoconus) — must be submitted with ICD-10 H18.609, H18.619, or H18.629.
CPT 92071 (fitting for treatment of ocular surface disease) — must be submitted with the specified ICD-10 codes (including H18.619, H18.629).

Eyeglasses or contact lenses are covered only when directly related to cataract or keratoconus and when prior authorized by Mass General Brigham Health Plan for Commercial and Medicare Advantage members.

Commonwealth Care members: routine vision benefits are managed by Spectera; contact Spectera. MassHealth members: contact MassHealth for requirements.

ALL of the following

CPT 92015 when billed for services not related to post-cataract extraction or treatment of keratoconus.
Eyewear (frames or contact lenses) not directly related to post-cataract surgery or keratoconus and not prior-authorized.
Services billed with an 'unassigned' place of service code.
Consultation services defined by CPT ranges 99242-99245 and 99252-99255.
Designer/luxury lenses and frames (e.g., Crystalens).
CPT 99177 when billed with a preventive service (deny as not reimbursable).

ALL of the following

Submit E/M services (CPT 92002-92014) with the most specific ICD-10 code(s) available; do not submit with ICD-10 H57.9 as primary for these claims.
All claims must be filed within 90 days of the date of service.

Applicable Codes, Billing Notes, and Claim Rules

Covered CPT CodesCPTCovered

92002-92014	Evaluation & Management services. Submit with the most specific ICD-10 code(s) available; claims should not be submitted with ICD-10 H57.9.
92071	Fitting of contact lens for treatment of ocular surface disease. Must be submitted with specified ICD-10 codes.
92072	Fitting of contact lens for management of keratoconus, initial fitting. Must be submitted with one of the following ICD-10 codes: H18.609, H18.619, H18.629.
92015	Determination of refractive state—reimbursed separately only when performed post-cataract surgery or for treatment of keratoconus. Must be submitted with one of the following ICD-10 diagnosis codes: H28.xx, H18.609, H18.619, H18.629.
99177	(See exclusions)

Claim filing window and diagnosis exclusions

Claim filing windowAll claims must be filed within 90 days of the date of service.

Primary diagnosis exclusions (do not bill as primary)H5Z9 (Unspecified disorder of the eye and adnexa); H5Z8 (Other specified disorders of eye and adnexa); H53.8 (Other visual disturbances); H53.9 (Unspecified visual disturbance).

Do-not-use guidance for E/M submissionsClaims for Evaluation & Management services (CPT 92002-92014) should not be submitted with ICD-10 code H57.9 as the diagnosis.

Referral, Prior Authorization, and Provider Requirements

Prior Authorization

Referral and prior authorization required for non-routine services

Contracted providers must obtain a referral for non-routine eye care. Prior authorization from Mass General Brigham Health Plan is required for non-contracted providers and for eye-related cosmetic surgery. For Commonwealth Care members, routine vision benefits are managed by Spectera and Spectera should be contacted for requirements.

Contracted providers: referral required for non-routine eye care.
Non-contracted providers: prior authorization required from Mass General Brigham Health Plan.
Eye-related cosmetic surgery: prior authorization required from Mass General Brigham Health Plan.
Commonwealth Care members: routine vision benefit managed by Spectera — contact Spectera for requirements.

Key Definitions

Definition of Optometrist

DefinitionOptometrist: Eye health care professionals who are state-licensed to diagnose and treat diseases and disorders of the eye and visual system.

Scope of practice (MA law)Under Massachusetts General Law optometrists are allowed to diagnose, manage and treat eye conditions and eye diseases.

Common services performedEvaluate the eye with dilated eye exams; prescribe corrective lenses; remove foreign objects from the eye; write prescriptions for therapeutic pharmaceutical agents (TPAs).

Definition of Ophthalmologist

DefinitionOphthalmologist: A medical doctor specializing in the diagnosis, management and treatment of diseases/disorders of the eye.

ExpertiseProvides medical and surgical care for eye diseases and disorders.