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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 Prescription, fitting & dispensing of contacts by doctor 92314 Prescription, fitting & dispensing of contacts by tech S0592 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.

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 /

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Transcription of EYEMED ACCEPTABLE SERVICE CODES

1 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 Prescription, fitting & dispensing of contacts by doctor 92314 Prescription, fitting & dispensing of contacts by tech S0592 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.

2 V2513 GAS PERMEABLE, EXTENDED. V2520 HYDROPHILIC, SPHERICAL. HDROPHILIC ASPH. COLOR. V2521 HYDROPHILIC, TORIC, PRISM. 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 Standard Frame V2025 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 . Effective 10/16/03. Lens CODES Basic Plastic Single Vision Lens CODES ACCEPTABLE code Modifier S0504 SINGLE VISION LENS (ATHLETIC, SUNGLASS). V2100 D. V2101 D. V2102 D. V2103 SPH;25 CYL. V2104 SPH; CYL. V2105 SPH; CYL. V2106 SPH; > CYL. V2107 SPH;25 CYL. V2108 SPH; CYL.

3 V2109 SPH; CYL. V2110 SPH; > CYL. V2111 SPH;25 CYL. V2112 SPH; CYL. V2113 SPH; CYL. V2114 > SPH. V2199 Specialty (explanation required). Basic Plastic Bifocal Vision Lens CODES S0506 BIFOCAL VISION LENS (ATHLETIC, SUNGLASS). V2200 D. V2201 D. V2202 D. V2203 SPH;25 CYL. V2204 SPH; CYL. V2205 SPH; CYL. V2206 SPH; > CYL. V2207 SPH;25 CYL. V2208 SPH; CYL. V2209 SPH; CYL. V2210 SPH; > CYL. V2211 SPH;25 CYL. V2212 SPH; CYL. V2213 SPH; CYL. V2214 > SPH. V2299 Specialty (explanation required). Basic Plastic Trifocal Vision Lens CODES S0508 TRIFOCAL VISION LENS (ATHLETIC, SUNGLASS). V2300 D. V2301 D. V2302 D. V2303 SPH;25 CYL. V2304 SPH; CYL. V2305 SPH; CYL. V2306 SPH; > CYL. V2307 SPH;25 CYL. V2308 SPH; CYL. V2309 SPH; CYL. V2310 SPH; > CYL. V2311 SPH;25 CYL. V2312 SPH; CYL. V2313 SPH; CYL. V2314 > SPH. V2399 Specialty (explanation required). EYEMED ACCEPTABLE SERVICE CODES . Effective 10/16/03.

4 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 >28mm (explanation required). V2219 Flat Top 35. V2219 Executive V2220 Add > V2319 >28mm (explanation required). V2319 Flat Top 35. V2319 Executive V2320 Add > Lens Add On and Material CODES ACCEPTABLE code Modifier V2799 Glass Lenses V2780 Oversize V2760 Scratch Coating V2740 - V2743 Solid or Gradient Plastic Rose Tint V2755 UV400. V2715 Prism V2744 Photochromic-glass V2750 Standard AR Coating V2700 Balance lens V2710 Slab-Off V2730 Special Base Curve S0580 Polycarbonate V2799 HI-Index V2799 Double Gradient Tint V2744 Photochromic-Plastic V2799 Roll & Polish V2799 Polaroid Lenses V2799 Mirror Coating V2799 Rimless/Drill OTHER CODES .

5 V2799 All Items eligible for 20% discount not listed above S9999 Sales Tax on Materials (if applicable). S0581 NONSTANDARD LENS (Used to show Premium Progressive). S1001 DELUXE ITEM, PATIENT AWARE. S1002 CUSTOMIZED ITEM. TG 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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