Two kinds of coverage, two sets of codes
Ophthalmology practices bill both medical insurance and routine vision plans, often for the same patient. Whether a visit is medical or routine depends on the reason for it and the diagnosis, not on the tests performed — and the answer decides which plan is billed, what the patient owes and which codes apply. On top of that come per-eye diagnostic tests, surgery with global periods and co-management, and expensive injectable drugs.
Exams, E/M and refraction
- Eye exam codes (92002, 92004, 92012, 92014) or office E/M codes (99202–99215) can be used for medical eye visits; the practice chooses whichever the documentation best supports, but never both for one visit.
- Refraction (92015) is not covered by Medicare and many medical plans, so it is collected from the patient or billed to a vision plan, with patients told in advance.
- Diabetic eye exams are medical services and are coded with the diabetes diagnosis, including any retinopathy.
Diagnostic testing per eye
Tests such as optical coherence tomography (92133, 92134), visual fields (92083) and fundus photography (92250) are defined as unilateral or bilateral in their descriptors, which decides whether RT, LT or a bilateral modifier is used. Each test needs a written order, an interpretation and a diagnosis that supports it, and many have frequency limits in payer policies.
Cataract surgery, co-management and premium lenses
| Item | How it is billed |
|---|---|
| Cataract surgery | 66984 (routine) or 66982 (complex, when documented), with RT or LT; 90-day global period |
| Co-management | Surgeon bills with modifier 54 (surgical care only); the other provider bills post-operative care with modifier 55, with a written transfer of care |
| Premium lenses | Medicare and many plans pay for a conventional lens; the extra cost of presbyopia- or astigmatism-correcting lenses is billed to the patient with advance notice |
| Facility | Billed separately by the ASC or hospital outpatient department |
Intravitreal injections and retina drugs
Intravitreal injections (67028) are billed per eye with RT or LT, or with modifier 50 when both eyes are treated, as each payer requires. The drug is billed with its HCPCS code and units, doubled for bilateral treatment; for single-dose vials Medicare requires modifier JW for discarded drug or JZ when none was discarded. Anti-VEGF drugs usually need prior authorization, and plans often require step therapy through a preferred product first — see prior authorization services.