Allowable Fees for Vision Care Services

(1) Modifiers. The following modifiers are used to adjust payments under the circumstances noted in 101 CMR 315.04(1)(a) and (b). (a) -52 Reduced Services. Modifier -52 is used to describe circumstances in which services provided were reduced in comparison to the full description of the service. When a provider does not complete a procedure in its entirety, such as a provider electing to partially reduce or eliminate a service, the procedure must be billed by appending modifier -52 to the service code. The rate for services billed with modifier -52 is 86% of the rate listed in 101 CMR 315.04(2). For example, modifier -52 would be used for a procedure that includes administration of eyedrops when an optometrist who is not certified to distribute eyedrops, performs the procedure. (b) Provider Preventable Conditions. The following modifiers are used to report provider preventable conditions in accordance with 42 CFR. 447.26 and result in nonpayment for services. Modifier PA Surgical or other invasive procedure performed on the wrong body part PB Surgical or other invasive procedure performed on the wrong patient PC Wrong surgical or other invasive procedure performed on a patient (2) Services and Payments Covered Under Other Regulations. Payments for some services performed by ophthalmologists are governed by other EOHHS regulations, including 101 CMR 316.00: Rates for Surgery and Anesthesia Services; and 101 CMR 317.00: Rates for Medicine Services. The following codes are included in 101 CMR 316.00: 65210, 65222, 67820, 67938, 68761, 68801, and 68840. The following codes are included in 101 CMR 317.00: 92132, 92133, 92134, 92201, 92202, 92227, 92228, 92250, 92273, 92274, 99174, and 99177. Ophthalmic ultrasound, diagnostic; B-scan (with or without superimposed non-quantitative A-scan) Ophthalmic ultrasound, diagnostic; anterior segment ultrasound, immersion (water bath) B-scan or high resolution biomicroscopy, unilateral or bilateral Ophthalmic ultrasound, diagnostic; corneal pachymetry, unilateral or bilateral (determination of corneal thickness) Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; intermediate, new patient Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; comprehensive, new patient, 1 or more visits Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established patient Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive, established patient, 1 or more visits Determination of refractive state Gonioscopy (separate procedure) Orthoptic training; performed by a physician or other qualified health care professional Visual field examination, unilateral or bilateral, with interpretation and report; limited examination (eg, tangent screen, Autoplot, arc perimeter, or single stimulus level automated test, such as Octopus 3 or 7 equivalent) Visual field examination, unilateral or bilateral, with interpretation and report; intermediate examination (eg, at least 2 isopters on Goldmann perimeter, or semiquantitative, automated suprathreshold screening program, Humphrey suprathreshold automatic diagnostic test, Octopus program 33) Visual field examination, unilateral or bilateral, with interpretation and report; extended examination (eg, Goldmann visual fields with at least 3 isopters plotted and static determination within the central 30 degrees or quantitative, automated threshold perimetry, Octopus program G-1, 32 or 42, Humphrey visual field analyzer full threshold programs 30-2, 24- 2, or 30/60-2) Serial tonometry (separate procedure) with multiple measurements of intraocular pressure over an extended time period with interpretation and report, same day (eg, diurnal curve or medical treatment of acute elevation of intraocular pressure) Ophthalmoscopy, extended, with retinal drawing (eg, for retinal detachment, melanoma), with interpretation and report; initial Ophthalmoscopy, extended, with retinal drawing (eg, for retinal detachment, melanoma), with interpretation and report; subsequent IC Imaging of retina for detection or monitoring of disease; point- of-care autonomous analysis and report, unilateral or bilateral Fluorescein angioscopy with interpretation and report Ophthalmodynamometry Electroretinography with interpretation and report External ocular photography with interpretation and report for documentation of medical progress (eg, close-up photography, slit lamp photography, goniophotography, stereo-photography) IC Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens, both eyes, except for aphakia Replacement of contact lens Fitting of spectacles, except for aphakia; monofocal 92340 RB Fitting of spectacles, except for aphakia; monofocal (replacement and repair) (per lens) Fitting of spectacles, except for aphakia; bifocal 92341 RB Fitting of spectacles, except for aphakia; bifocal (replacement and repair) (per lens) Fitting of spectacles, except for aphakia; multifocal, other than bifocal 92342 RB Fitting of spectacles, except for aphakia; multifocal, other than bifocal (replacement and repair) (per lens) Repair and refitting spectacles; except for aphakia IC Unlisted ophthalmological service or procedure Spontaneous nystagmus test, including gaze and fixation nystagmus, with recording Positional nystagmus test, minimum of 4 positions, with recording Optokinetic nystagmus test, bidirectional, foveal or peripheral stimulation, with recording Screening test of visual acuity, quantitative, bilateral Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 15 minutes must be met or exceeded. Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded. Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 45 minutes must be met or exceeded. Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 60 minutes must be met or exceeded. Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician or other qualified health care professional Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 10 minutes must be met or exceeded. Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 20 minutes must be met or exceeded. Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded. Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded. Office or other outpatient consultation for a new or established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 20 minutes must be met or exceeded. Office or other outpatient consultation for a new or established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded. Office or other outpatient consultation for a new or established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded. Office or other outpatient consultation for a new or established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 55 minutes must be met or exceeded. Inpatient or observation consultation for a new or established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 35 minutes must be met or exceeded. Inpatient or observation consultation for a new or established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 45 minutes must be met or exceeded. Inpatient or observation consultation for a new or established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 60 minutes must be met or exceeded. Initial nursing facility care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level of medical decision making. When using total time on the date of the encounter for code selection, 25 minutes must be met or exceeded. Initial nursing facility care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 35 minutes must be met or exceeded. Initial nursing facility care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 50 minutes must be met or exceeded. Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 10 minutes must be met or exceeded. Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 20 minutes must be met or exceeded. Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded. Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 45 minutes must be met or exceeded. Home or residence visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 15 minutes must be met or exceeded. Home or residence visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded. IC Home or residence visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 60 minutes must be met or exceeded. Home or residence visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 20 minutes must be met or exceeded. Home or residence visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded. Home or residence visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded. T2002 Nonemergency transportation; per diem FRAMES Frames, purchases IC Deluxe frame SINGLE VISION, GLASS OR PLASTIC If procedure code 92395 is reported, recode with specific lens type below. Sphere, single vision, plano to plus or minus 4.00, per lens Sphere, single vision, plus or minus 4.12 to plus or minus 7.00d, per lens Sphere, single vision, plus or minus 7.12 to plus or minus 20.00d, per lens Spherocylinder, single vision, plano to plus or minus 4.00d sphere, 0.12 to 2.00d cylinder, per lens Spherocylinder, single vision, plano to plus or minus 4.00d sphere, 2.12 to 4.00d cylinder, per lens Spherocylinder, single vision, plano to plus or minus 4.00d sphere, 4.25 to 6.00d cylinder, per lens Spherocylinder, single vision, plano to plus or minus 4.00d sphere, over 6.00d cylinder, per lens Spherocylinder, single vision, plus or minus 4.25 to plus or minus 7.00 sphere, 0.12 to 2.00d cylinder, per lens Spherocylinder, single vision, plus or minus 4.25d to plus or minus 7.00d sphere, 2.12 to 4.00d cylinder, per lens Spherocylinder, single vision, plus or minus 4.25 to plus or minus 7.00d sphere, 4.25 to 6.00d cylinder, per lens Spherocylinder, single vision, plus or minus 4.25 to 7.00d sphere, over 6.00d cylinder, per lens Spherocylinder, single vision, plus or minus 7.25 to plus or minus 12.00d sphere, 0.25 to 2.25d cylinder, per lens Spherocylinder, single vision, plus or minus 7.25 to plus or minus 12.00d sphere, 2.25d to 4.00d cylinder, per lens Spherocylinder, single vision, plus or minus 7.25 to plus or minus 12.00d sphere, 4.25 to 6.00d cylinder, per lens Spherocylinder, single vision, sphere over plus or minus 12.00d, per lens Lenticular (myodisc), per lens, single vision Aniseikonic lens, single vision Lenticular lens, per lens, single IC Not otherwise classified, single vision lens BIFOCAL, GLASS OR PLASTIC Sphere, bifocal, plano to plus or minus 4.00d, per lens Sphere, bifocal, plus or minus 4.12 to plus or minus 7.00d, per lens Sphere, bifocal, plus or minus 7.12 to plus or minus 20.00d, per lens Spherocylinder, bifocal, plano to plus or minus 4.00d sphere, 0.12 to 2.00d cylinder, per lens Spherocylinder, bifocal, plano to plus or minus 4.00d sphere, 2.12 to 4.00d cylinder, per lens Spherocylinder, bifocal, plano to plus or minus 4.00d sphere, 4.25 to 6.00d cylinder, per lens Spherocylinder, bifocal, plano to plus or minus 4.00d sphere, over 6.00d cylinder, per lens Spherocylinder, bifocal, plus or minus 4.25 to plus or minus Spherocylinder, bifocal, plus or minus 4.25 to plus or minus Spherocylinder, bifocal, plus or minus 4.25 to plus or minus Spherocylinder, bifocal, plus or minus 4.25 to plus or minus 7.00d sphere, over 6.00d cylinder, per lens Spherocylinder, bifocal, plus or minus 7.25 to plus or minus Spherocylinder, bifocal, plus or minus 7.25 to plus or minus Spherocylinder, bifocal, plus or minus 7.25 to plus or minus Spherocylinder, bifocal, sphere over plus or minus 12.00d, per lens Lenticular (myodisc), per lens, bifocal Aniseikonic, per lens, bifocal Bifocal seg width over 28mm Bifocal add over 3.25d Lenticular lens, per lens, bifocal IC Specialty bifocal (by report) TRIFOCAL, GLASS OR PLASTIC Sphere, trifocal, plano to plus or minus 4.00d, per lens Sphere, trifocal, plus or minus 4.12 to plus or minus 7.00d per lens Sphere, trifocal, plus or minus 7.12 to plus or minus 20.00, per lens Spherocylinder, trifocal, plano to plus or minus 4.00d sphere, 0.12 to 2.00d cylinder, per lens Spherocylinder, trifocal, plano to plus or minus 4.00d sphere, 2.25 to 4.00d cylinder, per lens Spherocylinder, trifocal, plano to plus or minus 4.00d sphere, 4.25 to 6.00 cylinder, per lens Spherocylinder, trifocal, plano to plus or minus 4.00d sphere, over 6.00d cylinder, per lens Spherocylinder, trifocal, plus or minus 4.25 to plus or minus Spherocylinder, trifocal, plus or minus 4.25 to plus or minus Spherocylinder, trifocal, plus or minus 4.25 to plus or minus Spherocylinder, trifocal, plus or minus 4.25 to plus or minus 7.00d sphere, over 6.00d cylinder, per lens Spherocylinder, trifocal, plus or minus 7.25 to plus or minus Spherocylinder, trifocal, plus or minus 7.25 to plus or minus Spherocylinder, trifocal, plus or minus 7.25 to plus or minus Spherocylinder, trifocal, sphere over plus or minus 12.00d, per lens Lenticular, (myodisc), per lens, trifocal Aniseikonic lens, trifocal Trifocal seg width over 28 mm Trifocal add over 3.25d Lenticular lens, per lens, trifocal IC Specialty trifocal (by report) VARIABLE ASPHERICITY Variable asphericity lens, single vision, full field, glass or plastic, per lens Variable asphericity lens, bifocal, full field, glass or plastic, per lens IC Variable sphericity lens, other type CONTACT LENSES If procedure code 92396 is reported, recode with specific lens type listed below (per lens). Contact lens, PMMA, spherical, per lens Contact lens, PMMA, toric or prism ballast, per lens Contact lens PMMA, bifocal, per lens Contact lens, PMMA, color vision deficiency, per lens Contact lens, gas permeable, spherical, per lens Contact lens, gas permeable, toric, prism ballast, per lens Contact lens, gas permeable, bifocal, per lens Contact lens, gas permeable, extended wear, per lens Contact lens, hydrophilic, spherical, per lens Contact lens, hydrophilic, toric, or prism ballast, per lens Contact lens, hydrophilic, bifocal, per lens Contact lens, hydrophilic, extended wear, per lens IC Contact lens, scleral, gas impermeable, per lens (for contact lens modification, see 92325) IC Contact lens, scleral, gas permeable, per lens (for contact lens modification, see 92325) IC Contact lens, other type LOW-VISION AIDS If procedure code 92392 is reported, recode with specific systems listed below. IC Handheld low vision aids and other nonspectacle mounted aids IC Single lens spectacle mounted low vision aids IC Telescopic and other compound lens system, including distance vision telescopic, near vision telescopes and compound microscopic lens system PROSTHETIC EYE IC Prosthetic eye, plastic, custom IC Polishing/resurfacing of ocular prosthesis IC Enlargement of ocular prosthesis IC Reduction of ocular prosthesis IC Scleral cover shell IC Fabrication and fitting of ocular conformer IC Prosthetic eye, other type INTRAOCULAR LENSES IC Anterior chamber intraocular lens IC Iris supported intraocular lens IC Posterior chamber intraocular lens MISCELLANEOUS Balance lens, per lens Slab off prism, glass or plastic, per lens Prism, per lens Press-on lens, Fresnel prism, per lens Special base curve, glass or plastic, per lens Tint, photochromatic, per lens Addition to lens; tint, any color, solid, gradient or equal, excludes photochromatic, any lens material, per lens Antireflective coating, per lens U-V lens, per lens Scratch resistant coating, per lens Occluder lens, per lens Oversize lens, per lens IC Progressive lens, per lens IC Processing, preserving and transporting corneal tissue IC Presbyopia correcting function of intraocular lens IC Vision item or service, miscellaneous