EYEMED ACCEPTABLE SERVICE CODES
[Pages:3]EYEMED ACCEPTABLE SERVICE CODES
Effective 10/16/03
Exam & Fit/Follow Up Services
Acceptable
Code Modifier
92002
New Intermediate
92004
New Comprehensive
92012
Established Intermediate
92014
Established Comprehensive
S0620
Routine Opthalmological - New Patient
S0621
Routine Opthalmological - Established Patient
92015 TG
VDT Refraction (Valid only on certain plans)
92310 92314 S0592
Prescription, fitting & dispensing of contacts by doctor Prescription, fitting & dispensing of contacts by tech Comprehensive Contact Lens Evaluation
Contact Lens Materials
Acceptable
Code Modifier
S0500
ALL DISPOSABLE/PLANNED REPLACEMENT CONTACTS
S0512
DAILY WEAR SPECIALTY CONTACTS
V2330
CONTACT LENS, SCLERAL
V2500
PMMA, SPHERICAL
V2501
PMMA TORIC OR PRISM BALLA
V2502
PMMA, BIFOCAL
V2503
PMMA, COLOR VISION DEFIC
Please Note: A "D" after the
V2510
GAS PERMEABLE, SPHERICAL
"V" code will no longer
V2511
GAS PERM, TORIC, PRISM
identify the contacts as
V2512
GAS PERMEABLE, BIFOCAL
a disposable contact lens.
V2513
GAS PERMEABLE, EXTENDED
V2520
HYDROPHILIC, SPHERICAL
V2520.1
HDROPHILIC ASPH. COLOR
V2521
HYDROPHILIC, TORIC, PRISM
V2521.1
HYDROPHILIC TORIC EW
V2522
HYDOPHILIC, BIFOCAL
V2523
HYDROPHILIC, EXTENDED
V2530
CONTACT LENS, SCLERAL
V2531
CONTACT LENS, SCLERAL, GP
V2599
OTHER CONTACT LENSES
Frame Codes
Acceptable Code Modifier V2020 V2025
Standard Frame Deluxe Frame
Note: We are requesting that you continue to include the Luxottica Manufacturer ID (IE BB109) in your claims submission process. We are working with the CMS and AMA to develop codes to allow us to identify Luxottica frames in the future.
EYEMED ACCEPTABLE SERVICE CODES
Lens Codes
Effective 10/16/03
Basic Plastic Single Vision Lens Codes Acceptable
Code Modifier
S0504 V2100 V2101
SINGLE VISION LENS (ATHLETIC, SUNGLASS) PL/4.00 D 4.25/7.00 D
V2102 V2103
7.25/20.00 D PL/4.00 SPH;25/2.00 CYL
V2104 V2105 V2106
PL/4.00 SPH;2.25/4.00 CYL PL/4.00 SPH;4.25/6.00 CYL PL/4.00 SPH; >6.00 CYL
V2107 V2108 V2109
4.25/7.00 SPH;25/2.00 CYL 4.25/7.00 SPH;2.25/4.00 CYL 4.25/7.00 SPH;4.25/6.00 CYL
V2110 V2111
4.25/7.00 SPH; > 6.00 CYL 7.25/12.00 SPH;25/2.00 CYL
V2112 V2113 V2114
7.25/12.00 SPH;2.25/4.00 CYL 7.25/12.00 SPH;4.25/6.00 CYL
> 12.00 SPH
V2199
Specialty (explanation required)
Basic Plastic Bifocal Vision Lens Codes
S0506
BIFOCAL VISION LENS (ATHLETIC, SUNGLASS)
V2200
PL/4.00 D
V2201
4.25/7.00 D
V2202
7.25/20.00 D
V2203
PL/4.00 SPH;25/2.00 CYL
V2204
PL/4.00 SPH;2.25/4.00 CYL
V2205
PL/4.00 SPH;4.25/6.00 CYL
V2206
PL/4.00 SPH; >6.00 CYL
V2207
4.25/7.00 SPH;25/2.00 CYL
V2208
4.25/7.00 SPH;2.25/4.00 CYL
V2209
4.25/7.00 SPH;4.25/6.00 CYL
V2210
4.25/7.00 SPH; > 6.00 CYL
V2211
7.25/12.00 SPH;25/2.00 CYL
V2212
7.25/12.00 SPH;2.25/4.00 CYL
V2213
7.25/12.00 SPH;4.25/6.00 CYL
V2214
> 12.00 SPH
V2299
Specialty (explanation required)
Basic Plastic Trifocal Vision Lens Codes
S0508
TRIFOCAL VISION LENS (ATHLETIC, SUNGLASS)
V2300
PL/4.00 D
V2301
4.25/7.00 D
V2302
7.25/20.00 D
V2303
PL/4.00 SPH;25/2.00 CYL
V2304
PL/4.00 SPH;2.25/4.00 CYL
V2305
PL/4.00 SPH;4.25/6.00 CYL
V2306
PL/4.00 SPH; >6.00 CYL
V2307
4.25/7.00 SPH;25/2.00 CYL
V2308
4.25/7.00 SPH;2.25/4.00 CYL
V2309
4.25/7.00 SPH;4.25/6.00 CYL
V2310
4.25/7.00 SPH; > 6.00 CYL
V2311
7.25/12.00 SPH;25/2.00 CYL
V2312
7.25/12.00 SPH;2.25/4.00 CYL
V2313
7.25/12.00 SPH;4.25/6.00 CYL
V2314
> 12.00 SPH
V2399
Specialty (explanation required)
EYEMED ACCEPTABLE SERVICE CODES
Effective 10/16/03
Plastic Progressive Lenses Acceptable
Code Modifier
V2781
Standard Progressive Lens
Please refer to your Provider Manual
V2781 \ | --------
Premium Progressive Lens
for the complete list of approved premium progressive lenses
S0581 / NOTE: To show "Premium Progressive" the S0581 code must be directly below
the V2781 to modify the meaning of the progressive. Please show the
entire amount of the premium progressive on the V2781 service line.
Other Bifocal/Trifocal Lenses
Acceptable
Code Modifier
V2219
Seg.width>28mm (explanation required)
V2219
Flat Top 35
V2219
Executive
V2220
Add >3.25D
V2319
Seg.width>28mm (explanation required)
V2319
Flat Top 35
V2319
Executive
V2320
Add >3.25D
Lens Add On and Material Codes
Acceptable Code Modifier V2799 V2780 V2760
V2740 - V2743 V2755 V2715 V2744 V2750 V2700 V2710 V2730 S0580 V2799 V2799 V2744 V2799 V2799 V2799 V2799
Glass Lenses Oversize Scratch Coating Solid or Gradient Plastic Rose Tint UV400 Prism Photochromic-glass Standard AR Coating Balance lens Slab-Off Special Base Curve Polycarbonate HI-Index Double Gradient Tint Photochromic-Plastic Roll & Polish Polaroid Lenses Mirror Coating Rimless/Drill
OTHER CODES V2799 S9999 S0581 S1001 S1002 TG
All Items eligible for 20% discount not listed above Sales Tax on Materials (if applicable) NONSTANDARD LENS (Used to show Premium Progressive) DELUXE ITEM, PATIENT AWARE CUSTOMIZED ITEM COMPLEX/HIGH TECH LEVEL OF CARE (Used to show VDT Refraction)
Please Note: For all Lens Add On Materials which are deemed Modifiers as the code type, the appropriate code MUST be shown directly below the Item (Lens) it is modifying to receive/calculate benefits correctly.
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