CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Billing and Reimbursement Guideline: Ophthalmology exams and testing

Defines coding, documentation, and reimbursement guidance for comprehensive and non-routine eye examinations and related ophthalmic testing for Neighborhood Health Plan of Rhode Island providers.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyBilling and Reimbursement Guideline: Ophthalmology exams and testing

Policy CodePolicy N/A

Change TypeFormat change and minor edits (9/1/2013)

Effective DateSep 1, 2010

Next Review DateN/A

Key ActionSubmit the date of service as the date when all exam components are completed and documented when components occur on different days.

SourceLink

POLICY UPDATE CHANGES

Format change and minor edits were made on 9/1/2013.

92002-92014Comprehensive exam codes

99201-99350E/M codes for non-routine exams

92225-92284Visual field testing codes (not reimbursed as unilateral with -50)

22,26,32,...Examples of valid modifiers

Ophthalmology Billing and Reimbursement Criteria

Ophthalmology billing criteria

Key reimbursement and billing points for comprehensive and non-routine ophthalmic services.

Comprehensive exam coding uses general ocular medical examination CPT codes 92002-92014; other non-routine exams may be billed using Evaluation and Management (E/M) CPT codes 99201-99350.

When components of a comprehensive ophthalmology examination are provided on different days, the date of service submitted on the claim must be the date that all components are completed and documented.

Comprehensive exam components that should be documented include: history; general medical observation; external and ophthalmoscopic exam; confrontation visual fields; and basic sensorimotor exam.

Visual field testing: medical diagnostic evaluation is included in visual field testing and should not be reported separately. Codes 92225-92284 are considered unilateral.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyBilling and Reimbursement Guideline: Ophthalmology exams and testing

Policy CodePolicy N/A

Change TypeFormat change and minor edits (9/1/2013)

Effective DateSep 1, 2010

Next Review DateN/A

Key ActionSubmit the date of service as the date when all exam components are completed and documented when components occur on different days.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Exam, Testing Codes and Billing Restrictions

Ophthalmology exam and testing codesCPTCovered

92002-92014	General ocular medical examination — comprehensive eye exam codes
99201-99350	Evaluation and Management (E/M) services for non-routine exams
92225-92284	Visual field testing codes (considered unilateral)

Visual field bilateral billing restriction

Policy restrictionNeighborhood does not reimburse commercial and senior visual field testing (CPT 92225-92284) as unilateral when reported with a -50 (bilateral) modifier.

Code characterizationCodes 92225-92284 are considered unilateral.

Related billing noteMedical diagnostic evaluation is included in visual field testing and should not be reported separately.

Documentation supportNotes may be requested to support separate reimbursement of services.

Key Definitions and Required Documentation Elements

Comprehensive exam — definition and scope

DefinitionComprehensive eye examination — includes procedures in an intermediate exam plus dilated ophthalmoscopy, biomicroscopy if indicated, motor evaluation, mydriasis if indicated, initiation of diagnostic and treatment programs as indicated, and tonometry if indicated.

CodingReport using general ocular medical examination CPT codes 92002-92014.

Service alternativesOther non-routine exams may be billed using Evaluation and Management CPT codes 99201-99350.

Date of service ruleWhen components are provided over multiple days, the date of service submitted must be the date all components are completed and documented.

Required documentation elements

Required componentsHistory; general medical observation; external and ophthalmoscopic exam; confrontation visual fields; basic sensorimotor exam.

Documentation expectationWhen performing a comprehensive eye exam, these exam elements must be documented in the patient’s records.

Supporting notesNotes may be requested to support separate reimbursement of services.

Date of service linkageIf components occur on different days, the claim date must reflect the date all components are completed and documented.

OpenPayer

Billing and Reimbursement Guideline: Ophthalmology exams and testing

Ophthalmology Billing and Reimbursement Criteria

Exam, Testing Codes and Billing Restrictions

Documentation and Date-of-Service Requirements

Key Definitions and Required Documentation Elements