EYEMED ACCEPTABLE SERVICE CODES

EYEMED ACCEPTABLE SERVICE CODES

Exam & Fit/Follow Up Services

Acceptable

Code

Modifier

92002

92004

92012

92014

S0620

S0621

92015

TG

92310

92314

S0592

Effective 10/16/03

New Intermediate

New Comprehensive

Established Intermediate

Established Comprehensive

Routine Opthalmological - New Patient

Routine Opthalmological - Established Patient

VDT Refraction (Valid only on certain plans)

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

S0512

V2330

V2500

V2501

V2502

V2503

V2510

V2511

V2512

V2513

V2520

V2520.1

V2521

V2521.1

V2522

V2523

V2530

V2531

V2599

ALL DISPOSABLE/PLANNED REPLACEMENT CONTACTS

DAILY WEAR SPECIALTY CONTACTS

CONTACT LENS, SCLERAL

PMMA, SPHERICAL

PMMA TORIC OR PRISM BALLA

PMMA, BIFOCAL

PMMA, COLOR VISION DEFIC

Please Note: A "D" after the

GAS PERMEABLE, SPHERICAL

"V" code will no longer

GAS PERM, TORIC, PRISM

identify the contacts as

GAS PERMEABLE, BIFOCAL

a disposable contact lens.

GAS PERMEABLE, EXTENDED

HYDROPHILIC, SPHERICAL

HDROPHILIC ASPH. COLOR

HYDROPHILIC, TORIC, PRISM

HYDROPHILIC TORIC EW

HYDOPHILIC, BIFOCAL

HYDROPHILIC, EXTENDED

CONTACT LENS, SCLERAL

CONTACT LENS, SCLERAL, GP

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

SINGLE VISION LENS (ATHLETIC, SUNGLASS)

V2100

PL/4.00 D

V2101

4.25/7.00 D

V2102

7.25/20.00 D

V2103

PL/4.00 SPH;25/2.00 CYL

V2104

PL/4.00 SPH;2.25/4.00 CYL

V2105

PL/4.00 SPH;4.25/6.00 CYL

V2106

PL/4.00 SPH; >6.00 CYL

V2107

4.25/7.00 SPH;25/2.00 CYL

V2108

4.25/7.00 SPH;2.25/4.00 CYL

V2109

4.25/7.00 SPH;4.25/6.00 CYL

V2110

4.25/7.00 SPH; > 6.00 CYL

V2111

7.25/12.00 SPH;25/2.00 CYL

V2112

7.25/12.00 SPH;2.25/4.00 CYL

V2113

7.25/12.00 SPH;4.25/6.00 CYL

V2114

> 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

\

for the complete list of approved

| -------Premium Progressive Lens

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

OTHER CODES

V2799

S9999

S0581

S1001

S1002

TG

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

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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