EYEMED ACCEPTABLE SERVICE CODES

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.

 ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download