CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Billing and Reimbursement Guideline: Vision Care Documentation and Billing Guidelines

Defines billing, documentation, coding and reimbursement expectations for vision care services and hardware for Neighborhood Health Plan of Rhode Island providers; affects all providers submitting vision-related claims to NHPRI.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyVision Care Documentation and Billing Guidelines

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJul 1, 2011

Next Review Date

Key ActionBill services under the rendering provider's name and NPI and consistently use either the ordering date or the pick-up date when billing hardware.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2original/revision dates

2records required after 2nd pair

1CPT codes cited

Vision Care Reimbursement Criteria

Vision care reimbursement criteria

Reimbursement and billing rules for eyeglasses and related services.

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Services should be billed under the rendering provider name and NPI number.

When billing for hardware, the date of service must be either the ordering date or the pick‑up date (not both); bill consistently using one method.

The diagnosis billed must support the charges and reflect the patient's condition; all services must be billed according to ICD-9, CPT and HCPC guidelines.

Repair or replacement due to materials/workmanship

Eyeglasses should not be billed to NHPRI when repair or replacement is required due to defects in quality of materials or workmanship; such items should be returned to the manufacturer.
Reimbursement is available for repair or replacement of eyeglass parts when damage is due to causes other than defective materials or workmanship; replacement parts should duplicate the original prescription and frame style.

Repairs or replacement of parts can be reported with CPT code 92370.

Reimbursement is available for replacement of lost or destroyed eyeglasses when medically necessary; the replacement complete pair should duplicate the original prescription and frames, and the member record must document the circumstances surrounding the replacement.

Patient records are required for all frames submitted after the second pair rendered to the same patient in a 12‑month period; patient records should include the pickup date and signature of the person picking up the eyeglasses.

NHPRI reserves the right to recoup funds for any service not documented in the patient record.

This guideline applies to both CMS-1500 and UB-92 claim submissions and to all places of service.

Coding and Record Requirements

Example CPT code for eyeglass repair/replacementCPTCovered

92370

Repair or replace eyeglass parts (as cited for reporting repairs/replacements)

Frames record requirement

RequirementPatient records are required for all frames submitted after the second pair rendered to the same patient within a 12‑month period.

Record contentsPatient records should include the pickup date and the signature of the person picking up the eyeglasses.

PurposeNHPRI may recoup funds for any service not documented in the patient record.

Provider Billing and Documentation Actions

Billing Rule

Bill under rendering provider name/NPI; use one consistent hardware date-of-service method

Services must be billed under the rendering provider’s name and NPI. When submitting claims for hardware (eyeglasses), use either the ordering date or the pick-up date as the date of service — do not use both — and apply the chosen method consistently.

Ensure the diagnosis billed supports the charges and reflects the patient’s condition.
Bill all services according to ICD-9, CPT and HCPC guidelines.

Key Definitions

Date of service (hardware)

DefinitionFor hardware (eyeglasses), the date of service should be either the ordering date or the pickup date; bill consistently using one method.

Billing instructionDo not use both ordering date and pickup date on the same claim for hardware.

ConsistencyChoose one date method (ordering or pickup) and apply it consistently across submissions.

Rendering provider

DefinitionServices should be billed under the rendering provider name and NPI number.

Claiming guidanceEnsure the rendering provider and corresponding NPI are included on all vision services submissions.

DocumentationRendering provider information supports attribution of service for reimbursement and audit purposes.