Two insurance worlds in one exam lane
Doctors of optometry provide both routine vision care and medical eye care, so a single practice bills two very different kinds of plans: vision plans that pay for eye exams, frames, lenses and contacts on their own schedules, and medical plans that pay for diagnosing and treating eye disease. The same patient may need both on the same day. Choosing the right plan, separating materials from services and collecting the patient’s share at checkout are the core of optometry billing.
Vision plan or medical plan
| Reason for the visit | Usually billed to | Typical codes |
|---|---|---|
| Routine exam, glasses or contacts, no medical complaint | Vision plan | Routine exam codes and refraction per plan |
| Eye disease, injury, red eye, diabetic eye exam, glaucoma follow-up | Medical plan | 92002–92014 or 99202–99215, with the medical diagnosis |
| Contact lens fitting | Vision plan or patient | Contact lens evaluation and fitting fees per plan; 92310 and related codes for medical necessity cases |
The deciding factor is the patient’s complaint and the diagnosis, not the tests performed. Refraction is not covered by Medicare or most medical plans and is collected from the patient or billed to the vision plan.
Materials: frames, lenses and contacts
- Vision plan materials are billed with the plan’s allowances, copays and lab rules, and the practice tracks what the plan pays versus what the patient owes for upgrades.
- Medical materials: Medicare covers one pair of conventional glasses or contact lenses after cataract surgery with an intraocular lens, billed with V-codes by a DME-enrolled supplier.
- Medically necessary contact lenses — for example for keratoconus — may be covered by medical or vision plans with documentation.
Medical eye care, testing and co-management
Optometrists bill medical visits, diagnostic tests such as OCT and visual fields (with laterality and a supporting diagnosis), and treatments within their state scope of practice. In co-managed cataract and refractive cases, the optometrist bills post-operative care with the surgery code and modifier 55 after the written transfer of care. Each optometrist must be credentialed with both vision and medical plans. For surgical eye care, see ophthalmology billing.