CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Ophthalmology exam billing and reimbursement

Guidance for coding, documentation, and reimbursement of ophthalmology examinations for providers submitting claims to Neighborhood Health Plan of Rhode Island; applies to CMS-1500 and UB-92 claim submissions and all product lines (see payer site).

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyOphthalmology exam billing and reimbursement

Policy CodePolicy N/A

Change TypeMinor editorial/formatting

Effective DateSep 1, 2010

Next Review DateN/A

Key ActionNotes may be requested to support separate reimbursement of services.

SourceLink

POLICY UPDATE CHANGES

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

92002-92014Comprehensive exam codes

99201-99350E/M codes (non-routine)

92225-92284Visual field testing (unilateral)

22,26,32,51...Valid modifiers

59,76,77,78...Post-op modifiers

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyOphthalmology exam billing and reimbursement

Policy CodePolicy N/A

Change TypeMinor editorial/formatting

Effective DateSep 1, 2010

Next Review DateN/A

Key ActionNotes may be requested to support separate reimbursement of services.

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.

Ophthalmology billing and documentation rules

Billing and reimbursement criteria and rules

Comprehensive eye examination may be billed using CPT codes 92002-92014 (general ocular medical examination).

Non-routine exams may be billed using evaluation and management (E/M) CPT codes 99201-99350.
When medical diagnostic evaluation is performed as part of visual field testing, it is included and should not be reported separately.

Components of a comprehensive ophthalmology examination may be provided in one visit or on subsequent days; the date of service billed must be the date that all components are completed and documented.

Visual field testing CPT codes 92225-92284 are considered unilateral and Neighborhood does not reimburse commercial and senior visual field testing billed as unilateral procedures with a -50 (bilateral) modifier.

Valid modifiers: 22, 26, 32, 51, 52, 53, 55, 56, 57, 58.

Valid post-operative modifiers: 59, 76, 77, 78, 79, 90, 99.

Notes may be requested to support separate reimbursement of services.

This guideline applies to both CMS-1500 and UB-92 claim submissions; refer to the provider website for product-line specific provisions as plan coverage, eligibility and claim payment edit rules may apply.

Exam and Testing Codes; Date of Service

Ophthalmology exam and visual field testing codesCPT

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

Date of service rule

Date of service ruleThe date of service billed must be the date that all components of the comprehensive ophthalmology examination are completed and documented.

Components timingComponents of a comprehensive examination may be provided in one visit or on a subsequent day; claim date must reflect completion of all components.

Claim submissionsThis guideline applies to both CMS-1500 and UB-92 claim submissions.

Documentation, Product-line Provisions, and Claims Actions

Documentation Required

Documentation requests

Notes may be requested to support separate reimbursement of services; providers should retain and submit clinical documentation when requested to substantiate billing for distinct services.

Retain exam notes that document elements of the service billed (history, external and ophthalmoscopic exam, confrontation visual fields, etc.).
Submit records promptly when Neighborhood requests notes to support separate reimbursement.

Denial Risk

Product-line provisions and edits

Refer to Neighborhood's provider website for product-line specific provisions; plan coverage, eligibility and claim payment edit rules may apply and this guideline is not a guarantee of reimbursement.

Check the payer website for any product-line limitations or claim-edit rules before billing.
Understand that applicable plan coverage and eligibility determinations can affect payment.

Exam Definitions and Required Elements

Comprehensive ophthalmology examination

CPT codes for comprehensive exam92002-92014 (general ocular medical examination)

Included exam elementsIncludes elements of an intermediate exam plus dilated ophthalmoscopy, motor evaluation, biomicroscopy if indicated, examination with cycloplegia or mydriasis if indicated, tonometry if indicated, and initiation of diagnostic and treatment programs as indicated.

Alternate billing for non-routine examsNon-routine exams may be billed using E/M CPT codes 99201-99350.

Required documentation elements for comprehensive exam

Required documentation - historyHistory must be documented in the patient record.

Required documentation - general observationGeneral medical observation must be documented.

Required documentation - ocular exam elementsExternal and ophthalmoscopic exam; confrontation visual fields; basic sensorimotor exam must be documented.

OpenPayer

Ophthalmology exam billing and reimbursement

Billing and Reimbursement Rules

Exam and Testing Codes; Date of Service

Documentation, Product-line Provisions, and Claims Actions

Exam Definitions and Required Elements