No pre-authorization or PCP referral is required for routine eye exams or eyewear.
Each eye examination shall be a complete analysis of visual function and shall include (but not be limited to) the following components:
- medical history
- visual acuity
- color vision
- stereopsis and gross visual field screening
- determination of neurological integrity (including test of papillary response) and extra-ocular muscle function
- inspection of bulbar and palpebral conjunctiva
- external examination of ocular adnexa (including lids, orbits and nodes)
- slit lamp examination of corneas, anterior chambers and lenses
- tonometry, dilated fundus examination (if not contraindicated) and an assessment
- diagnosis and treatment plan including a written prescription for corrective lenses if necessary.
Refraction is considered an integral part of the exam that although separated by service code contributes to the findings and accuracy of provider care.
Routine exams that become medical
“Regardless of final diagnosis, a patient who presents for eye examination with no complaint must be reported as a routine eye examination (initial visit only) listing ICD-9 codes V72.0 or 367.0 through 367.9 as the primary diagnosis in box 21 and the diagnosis reference point in Box 24E of Form CMS-1500. Any medical diagnosis should be listed as secondary. The coverage of services rendered by an eye care provider is dependent on the purpose and presenting chief reason for the examination rather than on the ultimate and incidental diagnosis (es)”. Therefore, if a patient presents to a provider’s office for a routine examination, and during the course of the examination a medical diagnosis is discovered, the examination is still reported as routine.
This information is based on a Medicare determination, which can be found in the Medicare Carrier Manual, Part 3, under Coverage and Limitations 08-94 section 2323. CMS makes it very clear that coverage for ophthalmology exams is determined based on the "purpose for the exam" rather than the ultimate diagnosis of the patient's condition. Supporting documentation may be viewed here.
Additional clarification: When the patient presents primarily for their regular eye exam or as result of a need to check their glasses or contact lenses the primary diagnosis should reflect one of those indicated above. All incidental findings, e.g. dry eye syndrome, esophoria, headaches, blurred vision, eyestrain, diabetes, etc….should be reported in the secondary diagnosis section on the claim.
