Notification



Notification Issue Date:



Policy Attachment


Attachment to Policy # 07.13.13c


Attachment:A

Policy #:07.13.13c

Description:Contains the applicable codes for prescription lenses and visual devices for Commercial (non-Medicare Advantage) members

Title:Prescription Lenses and Visual Devices


Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.


CODING TABLE
Code SystemCode Number(s)
CPTN/A
ICD ProcedureN/A
ICD-10 DiagnosisA18.59 Other tuberculosis of eye

B05.81 Measles keratitis and keratoconjunctivitis

D89.811 Chronic graft-versus-host disease

D89.812 Acute on chronic graft-versus-host disease

H02.051 Trichiasis without entropian right upper eyelid

H02.052 Trichiasis without entropian right lower eyelid

H02.053 Trichiasis without entropian right eye, unspecified eyelid

H02.054 Trichiasis without entropian left upper eyelid

H02.055 Trichiasis without entropian left lower eyelid

H02.056 Trichiasis without entropian left eye, unspecified eyelid

H02.059 Trichiasis without entropian unspecified eye, unspecified eyelid

H02.89 Other specified disorders of eyelid

H02.9 Unspecified disorder of eyelid

H04.121 Dry eye syndrome of right lacrimal gland

H04.122 Dry eye syndrome of left lacrimal gland

H04.123 Dry eye syndrome of bilateral lacrimal glands

H04.129 Dry eye syndrome of unspecified lacrimal gland

H04.129 Dry eye syndrome of unspecified lacrimal gland

H04.141 Primary lacrimal gland atrophy, right lacrimal gland

H04.142 Primary lacrimal gland atrophy, left lacrimal gland

H04.143 Primary lacrimal gland atrophy, bilateral lacrimal glands

H04.149 Primary lacrimal gland atrophy, unspecified lacrimal gland

H04.151 Secondary lacrimal gland atrophy, right lacrimal gland

H04.152 Secondary lacrimal gland atrophy, left lacrimal gland

H04.153 Secondary lacrimal gland atrophy, bilateral lacrimal glands

H04.159 Secondary lacrimal gland atrophy, unspecified lacrimal gland

H04.19 Other specified disorders of lacrimal gland

H04.69 Other changes of lacrimal passages

H04.89 Other disorders of lacrimal system

H10.211 Acute toxic conjunctivitis, right eye

H10.212 Acute toxic conjunctivitis, left eye

H10.213 Acute toxic conjunctivitis, bilateral

H10.219 Acute toxic conjunctivitis, unspecified eye

H10.821 Rosacea conjunctivitis, right eye

H10.822 Rosacea conjunctivitis, left eye

H10.823 Rosacea conjunctivitis, bilateral

H10.829 Rosacea conjunctivitis, unspecified eye

H10.89 Other conjunctivitis

H11.241 Scarring of conjunctiva, right eye

H11.242 Scarring of conjunctiva, left eye

H11.243 Scarring of conjunctiva, bilateral

H11.249 Scarring of conjunctiva, unspecified eye

H16.101 Unspecified superficial keratitis, right eye

H16.102 Unspecified superficial keratitis, left eye

H16.103 Unspecified superficial keratitis, bilateral

H16.121 Filamentary keratitis, right eye

H16.122 Filamentary keratitis, left eye

H16.123 Filamentary keratitis, bilateral

H16.129 Filamentary keratitis, unspecified eye

H16.141 Punctate keratitis, right eye

H16.142 Punctate keratitis, left eye

H16.143 Punctate keratitis, bilateral

H16.149 Punctate keratitis, unspecified eye

H16.201 Unspecified keratoconjunctivitis, right eye

H16.202 Unspecified keratoconjunctivitis, left eye

H16.203 Unspecified keratoconjunctivitis, bilateral

H16.209 Unspecified keratoconjunctivitis, unspecified eye

H16.211 Exposure keratoconjunctivitis, right eye

H16.212 Exposure keratoconjunctivitis, left eye

H16.213 Exposure keratoconjunctivitis, bilateral

H16.219 Exposure keratoconjunctivitis, unspecified eye

H16.219 Exposure keratoconjunctivitis, unspecified eye

H16.221 Keratoconjunctivitis sicca, not specified as Sjogren's, right eye

H16.222 Keratoconjunctivitis sicca, not specified as Sjogren's, left eye

H16.223 Keratoconjunctivitis sicca, not specified as Sjogren's, bilateral

H16.229 Keratoconjunctivitis sicca, not specified as Sjogren's, unspecified eye

H16.231 Neurotrophic keratoconjunctivitis, right eye

H16.232 Neurotrophic keratoconjunctivitis, left eye

H16.233 Neurotrophic keratoconjunctivitis, bilateral

H16.239 Neurotrophic keratoconjunctivitis, unspecified eye

H16.239 Neurotrophic keratoconjunctivitis, unspecified eye

H16.251 Phlyctenular keratoconjunctivitis, right eye

H16.252 Phlyctenular keratoconjunctivitis, left eye

H16.253 Phlyctenular keratoconjunctivitis, bilateral

H16.259 Phlyctenular keratoconjunctivitis, unspecified eye

H16.261 Vernal keratoconjunctivitis, with limbar and corneal involvement, right eye

H16.262 Vernal keratoconjunctivitis, with limbar and corneal involvement, left eye

H16.263 Vernal keratoconjunctivitis, with limbar and corneal involvement, bilateral

H16.269 Vernal keratoconjunctivitis, with limbar and corneal involvement, unspecified eye

H16.291 Other keratoconjunctivitis, right eye

H16.292 Other keratoconjunctivitis, left eye

H16.293 Other keratoconjunctivitis, bilateral

H16.299 Other keratoconjunctivitis, unspecified eye

H17.00 Adherent leukoma, unspecified eye

H17.01 Adherent leukoma, right eye

H17.02 Adherent leukoma, left eye

H17.03 Adherent leukoma, bilateral

H17.10 Central corneal opacity, unspecified eye

H17.11 Central corneal opacity, right eye

H17.12 Central corneal opacity, left eye

H17.13 Central corneal opacity, bilateral

H17.811 Minor opacity of cornea, right eye

H17.812 Minor opacity of cornea, left eye

H17.813 Minor opacity of cornea, bilateral

H17.819 Minor opacity of cornea, unspecified eye

H17.821 Peripheral opacity of cornea, right eye

H17.822 Peripheral opacity of cornea, left eye

H17.823 Peripheral opacity of cornea, bilateral

H17.829 Peripheral opacity of cornea, unspecified eye

H17.89 Other corneal scars and opacities

H17.9 Unspecified corneal scar and opacity

H18.001 Unspecified corneal deposit, right eye

H18.002 Unspecified corneal deposit, left eye

H18.003 Unspecified corneal deposit, bilateral

H18.009 Unspecified corneal deposit, unspecified eye

H18.011 Anterior corneal pigmentations, right eye

H18.012 Anterior corneal pigmentations, left eye

H18.013 Anterior corneal pigmentations, bilateral

H18.019 Anterior corneal pigmentations, unspecified eye

H18.021 Argentous corneal deposits, right eye

H18.022 Argentous corneal deposits, left eye

H18.023 Argentous corneal deposits, bilateral

H18.029 Argentous corneal deposits, unspecified eye

H18.031 Corneal deposits in metabolic disorders, right eye

H18.032 Corneal deposits in metabolic disorders, left eye

H18.033 Corneal deposits in metabolic disorders, bilateral

H18.039 Corneal deposits in metabolic disorders, unspecified eye

H18.041 Kayser-Fleischer ring, right eye

H18.042 Kayser-Fleischer ring, left eye

H18.043 Kayser-Fleischer ring, bilateral

H18.049 Kayser-Fleischer ring, unspecified eye

H18.051 Posterior corneal pigmentations, right eye

H18.052 Posterior corneal pigmentations, left eye

H18.053 Posterior corneal pigmentations, bilateral

H18.059 Posterior corneal pigmentations, unspecified eye

H18.061 Stromal corneal pigmentations, right eye

H18.062 Stromal corneal pigmentations, left eye

H18.063 Stromal corneal pigmentations, bilateral

H18.069 Stromal corneal pigmentations, unspecified eye

H18.10 Bullous keratopathy, unspecified eye

H18.10 Bullous keratopathy, unspecified eye

H18.11 Bullous keratopathy, right eye

H18.12 Bullous keratopathy, left eye

H18.13 Bullous keratopathy, bilateral

H18.20 Unspecified corneal edema

H18.211 Corneal edema secondary to contact lens, right eye

H18.212 Corneal edema secondary to contact lens, left eye

H18.213 Corneal edema secondary to contact lens, bilateral

H18.219 Corneal edema secondary to contact lens, unspecified eye

H18.221 Idiopathic corneal edema, right eye

H18.222 Idiopathic corneal edema, left eye

H18.223 Idiopathic corneal edema, bilateral

H18.229 Idiopathic corneal edema, unspecified eye

H18.231 Secondary corneal edema, right eye

H18.232 Secondary corneal edema, left eye

H18.233 Secondary corneal edema, bilateral

H18.239 Secondary corneal edema, unspecified eye

H18.30 Unspecified corneal membrane change

H18.311 Folds and rupture in Bowman's membrane, right eye

H18.312 Folds and rupture in Bowman's membrane, left eye

H18.313 Folds and rupture in Bowman's membrane, bilateral

H18.319 Folds and rupture in Bowman's membrane, unspecified eye

H18.321 Folds in Descemet's membrane, right eye

H18.322 Folds in Descemet's membrane, left eye

H18.323 Folds in Descemet's membrane, bilateral

H18.329 Folds in Descemet's membrane, unspecified eye

H18.331 Rupture in Descemet's membrane, right eye

H18.332 Rupture in Descemet's membrane, left eye

H18.333 Rupture in Descemet's membrane, bilateral

H18.339 Rupture in Descemet's membrane, unspecified eye

H18.40 Unspecified corneal degeneration

H18.411 Arcus senilis, right eye

H18.412 Arcus senilis, left eye

H18.413 Arcus senilis, bilateral

H18.419 Arcus senilis, unspecified eye

H18.419 Arcus senilis, unspecified eye

H18.421 Band keratopathy, right eye

H18.422 Band keratopathy, left eye

H18.423 Band keratopathy, bilateral

H18.429 Band keratopathy, unspecified eye

H18.43 Other calcerous corneal degeneration

H18.441 Keratomalacia, right eye

H18.442 Keratomalacia, left eye

H18.443 Keratomalacia, bilateral

H18.449 Keratomalacia, unspecified eye

H18.449 Keratomalacia, unspecified eye

H18.451 Nodular corneal degeneration, right eye

H18.452 Nodular corneal degeneration, left eye

H18.453 Nodular corneal degeneration, bilateral

H18.459 Nodular corneal degeneration, unspecified eye

H18.459 Nodular corneal degeneration, unspecified eye

H18.461 Peripheral corneal degeneration, right eye

H18.462 Peripheral corneal degeneration, left eye

H18.463 Peripheral corneal degeneration, bilateral

H18.469 Peripheral corneal degeneration, unspecified eye

H18.49 Other corneal degeneration

H18.50 Unspecified hereditary corneal dystrophies

H18.51 Endothelial corneal dystrophy

H18.52 Epithelial (juvenile) corneal dystrophy

H18.53 Granular corneal dystrophy

H18.54 Lattice corneal dystrophy

H18.55 Macular corneal dystrophy

H18.59 Other hereditary corneal dystrophies

H18.601 Keratoconus, unspecified, right eye

H18.602 Keratoconus, unspecified, left eye

H18.603 Keratoconus, unspecified, bilateral

H18.609 Keratoconus, unspecified, unspecified eye

H18.611 Keratoconus, stable, right eye

H18.612 Keratoconus, stable, left eye

H18.613 Keratoconus, stable, bilateral

H18.619 Keratoconus, stable, unspecified eye

H18.621 Keratoconus, unstable, right eye

H18.622 Keratoconus, unstable, left eye

H18.623 Keratoconus, unstable, bilateral

H18.629 Keratoconus, unstable, unspecified eye

H18.70 Unspecified corneal deformity

H18.711 Corneal ectasia, right eye

H18.712 Corneal ectasia, left eye

H18.713 Corneal ectasia, bilateral

H18.719 Corneal ectasia, unspecified eye

H18.721 Corneal staphyloma, right eye

H18.722 Corneal staphyloma, left eye

H18.723 Corneal staphyloma, bilateral

H18.729 Corneal staphyloma, unspecified eye

H18.731 Descemetocele, right eye

H18.732 Descemetocele, left eye

H18.733 Descemetocele, bilateral

H18.739 Descemetocele, unspecified eye

H18.791 Other corneal deformities, right eye

H18.792 Other corneal deformities, left eye

H18.793 Other corneal deformities, bilateral

H18.799 Other corneal deformities, unspecified eye

H18.811 Anesthesia and hypoesthesia of cornea, right eye

H18.812 Anesthesia and hypoesthesia of cornea, left eye

H18.813 Anesthesia and hypoesthesia of cornea, bilateral

H18.819 Anesthesia and hypoesthesia of cornea, unspecified eye

H18.821 Corneal disorder due to contact lens, right eye

H18.822 Corneal disorder due to contact lens, left eye

H18.823 Corneal disorder due to contact lens, bilateral

H18.829 Corneal disorder due to contact lens, unspecified eye

H18.831 Recurrent erosion of cornea, right eye

H18.832 Recurrent erosion of cornea, left eye

H18.833 Recurrent erosion of cornea, bilateral

H18.839 Recurrent erosion of cornea, unspecified eye

H18.891 Other specified disorders of cornea, right eye

H18.892 Other specified disorders of cornea, left eye

H18.893 Other specified disorders of cornea, bilateral

H18.899 Other specified disorders of cornea, unspecified eye

H18.9 Unspecified disorder of cornea

H21.241 Degeneration of pupillary margin, right eye

H21.242 Degeneration of pupillary margin, left eye

H21.243 Degeneration of pupillary margin, bilateral

H21.249 Degeneration of pupillary margin, unspecified eye

H26.40 Unspecified secondary cataract

H26.411 Soemmering's ring, right eye

H26.412 Soemmering's ring, left eye

H26.413 Soemmering's ring, bilateral

H26.419 Soemmering's ring, unspecified eye

H26.491 Other secondary cataract, right eye

H26.492 Other secondary cataract, left eye

H26.493 Other secondary cataract, bilateral

H26.499 Other secondary cataract, unspecified eye

H27.00 Aphakia, unspecified eye

H27.01 Aphakia, right eye

H27.02 Aphakia, left eye

H27.03 Aphakia, bilateral

H52.211 Irregular astigmatism, right eye

H52.212 Irregular astigmatism, left eye

H52.213 Irregular astigmatism, bilateral

H52.219 Irregular astigmatism, unspecified eye

L12.1 Cicatricial pemphigoid

L12.30 Acquired epidermolysis bullosa, unspecified

L12.31 Epidermolysis bullosa due to drug

L12.35 Other acquired epidermolysis bullosa

L51.0 Nonbullous erythema multiforme

L51.1 Stevens-Johnson syndrome

L51.2 Toxic epidermal necrolysis [Lyell]

L51.3 Stevens-Johnson syndrome-toxic epidermal necrolysis overlap syndrome

L51.8 Other erythema multiforme

L51.9 Erythema multiforme, unspecified

M35.00 Sicca syndrome, unspecified

M35.01 Sicca syndrome with keratoconjunctivitis

M35.02 Sicca syndrome with lung involvement

M35.03 Sicca syndrome with myopathy

M35.04 Sicca syndrome with tubulo-interstitial nephropathy

M35.09 Sicca syndrome with other organ involvement

Q10.1 Congenital ectropion

Q10.2 Congenital entropion

Q10.3 Other congenital malformations of eyelid

Q10.4 Absence and agenesis of lacrimal apparatus

Q10.5 Congenital stenosis and stricture of lacrimal duct

Q10.6 Other congenital malformations of lacrimal apparatus

Q12.3 Congenital aphakia

Q13.4 Other congenital corneal malformations

Q15.0 Congenital glaucoma

Q15.9 Congenital malformation of eye, unspecified

S00.201A Unspecified superficial injury of right eyelid and periocular area, initial encounter

S00.201D Unspecified superficial injury of right eyelid and periocular area, subsequent encounter

S00.201S Unspecified superficial injury of right eyelid and periocular area, sequela

S00.202A Unspecified superficial injury of left eyelid and periocular area, initial encounter

S00.202D Unspecified superficial injury of left eyelid and periocular area, subsequent encounter

S00.202S Unspecified superficial injury of left eyelid and periocular area, sequela

S00.211A Abrasion of right eyelid and periocular area, initial encounter

S00.211D Abrasion of right eyelid and periocular area, subsequent encounter

S00.211S Abrasion of right eyelid and periocular area, sequela

S00.212A Abrasion of left eyelid and periocular area, initial encounter

S00.212D Abrasion of left eyelid and periocular area, subsequent encounter

S00.212S Abrasion of left eyelid and periocular area, sequela

S00.219A Abrasion of unspecified eyelid and periocular area, initial encounter

S00.221A Blister (nonthermal) of right eyelid and periocular area, initial encounter

S00.221D Blister (nonthermal) of right eyelid and periocular area, subsequent encounter

S00.221S Blister (nonthermal) of right eyelid and periocular area, sequela

S00.222A Blister (nonthermal) of left eyelid and periocular area, initial encounter

S00.222D Blister (nonthermal) of left eyelid and periocular area, subsequent encounter

S00.222S Blister (nonthermal) of left eyelid and periocular area, sequela

S00.241A External constriction of right eyelid and periocular area, initial encounter

S00.241D External constriction of right eyelid and periocular area, subsequent encounter

S00.241S External constriction of right eyelid and periocular area, sequela

S00.242A External constriction of left eyelid and periocular area, initial encounter

S00.242D External constriction of left eyelid and periocular area, subsequent encounter

S00.242S External constriction of left eyelid and periocular area, sequela

S00.251A Superficial foreign body of right eyelid and periocular area, initial encounter

S00.251D Superficial foreign body of right eyelid and periocular area, subsequent encounter

S00.251S Superficial foreign body of right eyelid and periocular area, sequela

S00.252A Superficial foreign body of left eyelid and periocular area, initial encounter

S00.252D Superficial foreign body of left eyelid and periocular area, subsequent encounter

S00.252S Superficial foreign body of left eyelid and periocular area, sequela

S00.261A Insect bite (nonvenomous) of right eyelid and periocular area, initial encounter

S00.261D Insect bite (nonvenomous) of right eyelid and periocular area, subsequent encounter

S00.261S Insect bite (nonvenomous) of right eyelid and periocular area, sequela

S00.262A Insect bite (nonvenomous) of left eyelid and periocular area, initial encounter

S00.262D Insect bite (nonvenomous) of left eyelid and periocular area, subsequent encounter

S00.262S Insect bite (nonvenomous) of left eyelid and periocular area, sequela

S00.271A Other superficial bite of right eyelid and periocular area, initial encounter

S00.271D Other superficial bite of right eyelid and periocular area, subsequent encounter

S00.271S Other superficial bite of right eyelid and periocular area, sequela

S00.272A Other superficial bite of left eyelid and periocular area, initial encounter

S00.272D Other superficial bite of left eyelid and periocular area, subsequent encounter

S00.272S Other superficial bite of left eyelid and periocular area, sequela

S05.01xA Injury of conjunctiva and corneal abrasion without foreign body, right eye, initial encounter

S05.01xD Injury of conjunctiva and corneal abrasion without foreign body, right eye, subsequent encounter

S05.01xS Injury of conjunctiva and corneal abrasion without foreign body, right eye, sequela

S05.02xA Injury of conjunctiva and corneal abrasion without foreign body, left eye, initial encounter

S05.02xD Injury of conjunctiva and corneal abrasion without foreign body, left eye, subsequent encounter

S05.02xS Injury of conjunctiva and corneal abrasion without foreign body, left eye, sequela

S05.21xA Ocular laceration and rupture with prolapse or loss of intraocular tissue, right eye, initial encounter

S05.21xD Ocular laceration and rupture with prolapse or loss of intraocular tissue, right eye, subsequent encounter

S05.21xS Ocular laceration and rupture with prolapse or loss of intraocular tissue, right eye, sequela

S05.22xA Ocular laceration and rupture with prolapse or loss of intraocular tissue, left eye, initial encounter

S05.22xD Ocular laceration and rupture with prolapse or loss of intraocular tissue, left eye, subsequent encounter

S05.22xS Ocular laceration and rupture with prolapse or loss of intraocular tissue, left eye, sequela

S05.31xA Ocular laceration without prolapse or loss of intraocular tissue, right eye, initial encounter

S05.31xD Ocular laceration without prolapse or loss of intraocular tissue, right eye, subsequent encounter

S05.31xS Ocular laceration without prolapse or loss of intraocular tissue, right eye, sequela

S05.32xA Ocular laceration without prolapse or loss of intraocular tissue, left eye, initial encounter

S05.32xD Ocular laceration without prolapse or loss of intraocular tissue, left eye, subsequent encounter

S05.32xS Ocular laceration without prolapse or loss of intraocular tissue, left eye, sequela

S05.51xA Penetrating wound with foreign body of right eyeball, initial encounter

S05.51xD Penetrating wound with foreign body of right eyeball, subsequent encounter

S05.51xS Penetrating wound with foreign body of right eyeball, sequela

S05.52xA Penetrating wound with foreign body of left eyeball, initial encounter

S05.52xD Penetrating wound with foreign body of left eyeball, subsequent encounter

S05.52xS Penetrating wound with foreign body of left eyeball, sequela

S05.61xA Penetrating wound without foreign body of right eyeball, initial encounter

S05.61xD Penetrating wound without foreign body of right eyeball, subsequent encounter

S05.61xS Penetrating wound without foreign body of right eyeball, sequela

S05.62xA Penetrating wound without foreign body of left eyeball, initial encounter

S05.62xD Penetrating wound without foreign body of left eyeball, subsequent encounter

S05.62xS Penetrating wound without foreign body of left eyeball, sequela

S05.71xA Avulsion of right eye, initial encounter

S05.71xD Avulsion of right eye, subsequent encounter

S05.71xS Avulsion of right eye, sequela

S05.72xA Avulsion of left eye, initial encounter

S05.72xD Avulsion of left eye, subsequent encounter

S05.72xS Avulsion of left eye, sequela

S05.8x1A Other injuries of right eye and orbit, initial encounter

S05.8x1D Other injuries of right eye and orbit, subsequent encounter

S05.8x1S Other injuries of right eye and orbit, sequela

S05.8x2A Other injuries of left eye and orbit, initial encounter

S05.8x2D Other injuries of left eye and orbit, subsequent encounter

S05.8x2S Other injuries of left eye and orbit, sequela

S05.91xA Unspecified injury of right eye and orbit, initial encounter

S05.91xD Unspecified injury of right eye and orbit, subsequent encounter

S05.91xS Unspecified injury of right eye and orbit, sequela

S05.92xA Unspecified injury of left eye and orbit, initial encounter

S05.92xD Unspecified injury of left eye and orbit, subsequent encounter

S05.92xS Unspecified injury of left eye and orbit, sequela

T26.11xA Burn of cornea and conjunctival sac, right eye, initial encounter

T26.11xD Burn of cornea and conjunctival sac, right eye, subsequent encounter

T26.11xS Burn of cornea and conjunctival sac, right eye, sequela

T26.12xA Burn of cornea and conjunctival sac, left eye, initial encounter

T26.12xD Burn of cornea and conjunctival sac, left eye, subsequent encounter

T26.12xS Burn of cornea and conjunctival sac, left eye, sequela

T26.61xA Corrosion of cornea and conjunctival sac, right eye, initial encounter

T26.61xD Corrosion of cornea and conjunctival sac, right eye, subsequent encounter

T26.61xS Corrosion of cornea and conjunctival sac, right eye, sequela

T26.62xA Corrosion of cornea and conjunctival sac, left eye, initial encounter

T26.62xD Corrosion of cornea and conjunctival sac, left eye, subsequent encounter

T26.62xS Corrosion of cornea and conjunctival sac, left eye, sequela

T66.xxxA Radiation sickness, unspecified, initial encounter

T66.xxxD Radiation sickness, unspecified, subsequent encounter

T66.xxxS Radiation sickness, unspecified, sequela

Z85.840 Personal history of malignant neoplasm of eye

Z94.7 Corneal transplant status

Z96.1 Presence of intraocular lens

Z98.41 Cataract extraction status, right eye

Z98.42 Cataract extraction status, left eye

Z98.49 Cataract extraction status, unspecified eye

Z98.890 Other Specified postprocedural states

HCPCS Level IITHE FOLLOWING CODES ARE CONSIDERED COVERED WHEN MEDICAL NECESSITY CRITERIA ARE MET, AND WHEN IN ACCORDANCE WITH THE INDIVIDUAL MEMBER BENEFIT CONTRACT:

FRAMES

V2020 Frames, purchases

SINGLE VISION LENS

V2100 Sphere, single vision, plano to plus or minus 4.00, per lens

V2101 Sphere, single vision, plus or minus 4.12 to plus or minus 7.00d, per lens

V2102 Sphere, single vision, plus or minus 7.12 to plus or minus 20.00d, per lens

V2103 Spherocylinder, single vision, plano to plus or minus 4.00d sphere, 0.12 to 2.00d cylinder, per lens

V2104 Spherocylinder, single vision, plano to plus or minus 4.00d sphere, 2.12 to 4.00d cylinder, per lens

V2105 Spherocylinder, single vision, plano to plus or minus 4.00d sphere, 4.25 to 6.00d cylinder, per lens

V2106 Spherocylinder, single vision, plano to plus or minus 4.00d sphere, over 6.00d cylinder, per lens

V2107 Spherocylinder, single vision, plus or minus 4.25 to plus or minus 7.00 sphere, 0.12 to 2.00d cylinder, per lens

V2108 Spherocylinder, single vision, plus or minus 4.25d to plus or minus 7.00d sphere, 2.12 to 4.00d cylinder, per lens

V2109 Spherocylinder, single vision, plus or minus 4.25 to plus or minus 7.00d sphere, 4.25 to 6.00d cylinder, per lens

V2110 Spherocylinder, single vision, plus or minus 4.25 to 7.00d sphere, over 6.00d cylinder, per lens

V2111 Spherocylinder, single vision, plus or minus 7.25 to plus or minus 12.00d sphere, 0.25 to 2.25d cylinder, per lens

V2112 Spherocylinder, single vision, plus or minus 7.25 to plus or minus 12.00d sphere, 2.25d to 4.00d cylinder, per lens

V2113 Spherocylinder, single vision, plus or minus 7.25 to plus or minus 12.00d sphere, 4.25 to 6.00d cylinder, per lens

V2114 Spherocylinder, single vision, sphere over plus or minus 12.00d, per lens

V2115 Lenticular (myodisc), per lens, single vision

V2118 Aniseikonic lens, single vision

V2121 Lenticular lens, per lens, single

V2199 Not otherwise classified, single vision lens

BIFOCAL LENS

V2200 Sphere, bifocal, plano to plus or minus 4.00d, per lens

V2201 Sphere, bifocal, plus or minus 4.12 to plus or minus 7.00d, per lens

V2202 Sphere, bifocal, plus or minus 7.12 to plus or minus 20.00d, per lens

V2203 Spherocylinder, bifocal, plano to plus or minus 4.00d sphere, 0.12 to 2.00d cylinder, per lens

V2204 Spherocylinder, bifocal, plano to plus or minus 4.00d sphere, 2.12 to 4.00d cylinder, per lens

V2205 Spherocylinder, bifocal, plano to plus or minus 4.00d sphere, 4.25 to 6.00d cylinder, per lens

V2206 Spherocylinder, bifocal, plano to plus or minus 4.00d sphere, over 6.00d cylinder, per lens

V2207 Spherocylinder, bifocal, plus or minus 4.25 to plus or minus 7.00d sphere, 0.12 to 2.00d cylinder, per lens

V2208 Spherocylinder, bifocal, plus or minus 4.25 to plus or minus 7.00d sphere, 2.12 to 4.00d cylinder, per lens

V2209 Spherocylinder, bifocal, plus or minus 4.25 to plus or minus 7.00d sphere, 4.25 to 6.00d cylinder, per lens

V2210 Spherocylinder, bifocal, plus or minus 4.25 to plus or minus 7.00d sphere, over 6.00d cylinder, per lens

V2211 Spherocylinder, bifocal, plus or minus 7.25 to plus or minus 12.00d sphere, 0.25 to 2.25d cylinder, per lens

V2212 Spherocylinder, bifocal, plus or minus 7.25 to plus or minus 12.00d sphere, 2.25 to 4.00d cylinder, per lens

V2213 Spherocylinder, bifocal, plus or minus 7.25 to plus or minus 12.00d sphere, 4.25 to 6.00d cylinder, per lens

V2214 Spherocylinder, bifocal, sphere over plus or minus 12.00d, per lens

V2215 Lenticular (myodisc), per lens, bifocal

V2218 Aniseikonic, per lens, bifocal

V2219 Bifocal seg width over 28mm

V2220 Bifocal add over 3.25d

V2221 Lenticular lens, per lens, bifocal

V2299 Specialty Bifocal (by report)

TRIFOCAL LENS

V2300 Sphere, trifocal, plano to plus or minus 4.00d, per lens

V2301 Sphere, trifocal, plus or minus 4.12 to plus or minus 7.00d per lens

V2302 Sphere, trifocal, plus or minus 7.12 to plus or minus 20.00, per lens

V2303 Spherocylinder, trifocal, plano to plus or minus 4.00d sphere, 0.12 to 2.00d cylinder, per lens

V2304 Spherocylinder, trifocal, plano to plus or minus 4.00d sphere, 2.25 to 4.00d cylinder, per lens

V2305 Spherocylinder, trifocal, plano to plus or minus 4.00d sphere, 4.25 to 6.00 cylinder, per lens

V2306 Spherocylinder, trifocal, plano to plus or minus 4.00d sphere, over 6.00d cylinder, per lens

V2307 Spherocylinder, trifocal, plus or minus 4.25 to plus or minus 7.00d sphere, 0.12 to 2.00d cylinder, per lens

V2308 Spherocylinder, trifocal, plus or minus 4.25 to plus or minus 7.00d sphere, 2.12 to 4.00d cylinder, per lens

V2309 Spherocylinder, trifocal, plus or minus 4.25 to plus or minus 7.00d sphere, 4.25 to 6.00d cylinder, per lens

V2310 Spherocylinder, trifocal, plus or minus 4.25 to plus or minus 7.00d sphere, over 6.00d cylinder, per lens

V2311 Spherocylinder, trifocal, plus or minus 7.25 to plus or minus 12.00d sphere, 0.25 to 2.25d cylinder, per lens

V2312 Spherocylinder, trifocal, plus or minus 7.25 to plus or minus 12.00d sphere, 2.25 to 4.00d cylinder, per lens

V2313 Spherocylinder, trifocal, plus or minus 7.25 to plus or minus 12.00d sphere, 4.25 to 6.00d cylinder, per lens

V2314 Spherocylinder, trifocal, sphere over plus or minus 12.00d, per lens

V2315 Lenticular, (myodisc), per lens, trifocal

V2318 Aniseikonic lens, trifocal

V2319 Trifocal seg width over 28 mm

V2320 Trifocal add over 3.25d

V2321 Lenticular lens, per lens, trifocal

V2399 Specialty trifocal (by report)

VARIABLE ASPHERICITY LENS

V2410 Variable asphericity lens, single vision, full field, glass or plastic, per lens

V2430 Variable asphericity lens, bifocal, full field, glass or plastic, per lens

V2499 Variable sphericity lens, other type

CONTACT LENS

V2500 Contact lens, PMMA, spherical, per lens

V2501 Contact lens, PMMA, toric or prism ballast, per lens

V2502 Contact lens PMMA, bifocal, per lens

V2503 Contact lens, PMMA, color vision deficiency, per lens

V2510 Contact lens, gas permeable, spherical, per lens

V2511 Contact lens, gas permeable, toric, prism ballast, per lens

V2512 Contact lens, gas permeable, bifocal, per lens

V2513 Contact lens, gas permeable, extended wear, per lens

V2520 Contact lens, hydrophilic, spherical, per lens

V2521 Contact lens, hydrophilic, toric, or prism ballast, per lens

V2522 Contact lens, hydrophilic, bifocal, per lens

V2523 Contact lens, hydrophilic, extended wear, per lens

V2530 Contact lens, scleral, gas impermeable, per lens (for contact lens modification, see 92325)

V2531 Contact lens, scleral, gas permeable, per lens (for contact lens modification, see 92325)

V2599 Contact lens, other type

OTHER LENSES

S0500 Disposable contact lens, per lens

S0512 Daily wear specialty contact lens, per lens

S0515 Scleral lens, liquid bandage device, per lens

V2700 Balance lens, per lens

V2770 Occluder lens, per lens

THE FOLLOWING CODES ARE CONSIDERED NON-COVERED ACCORDING TO THE INDIVIDUAL MEMBER BENEFIT CONTRACT:

VISION AIDS

V2600 Hand held low vision aids and other nonspectacle mounted aids

V2610 Single lens spectacle mounted low vision aids

V2615 Telescopic and other compound lens system, including distance vision telescopic, near vision telescopes and compound microscopic lens system

DELUXE FRAME AND LENS

V2025 Deluxe frame

V2702 Deluxe lens feature

MISCELLANEOUS

S0504 Single vision prescription lens (safety, athletic, or sunglass), per lens

S0506 Bifocal vision prescription lens (safety, athletic, or sunglass), per lens

S0508 Trifocal vision prescription lens (safety, athletic, or sunglass), per lens

S0510 Nonprescription lenses

S0580 Polycarbonate lens (list this code in addition to the basic code for the lens)

S0581 Nonstandard lens (list this code in addition to the basic code for the lens)

S0590 Integral lens service, miscellaneous services reported separately

S0595 Dispensing new spectacle lenses for patient supplied frame

V2744 Tint, photochromatic, per lens

V2745 Addition to lens; tint, any color, solid, gradient or equal, excludes photochromatic, any lens material, per lens

V2750 Antireflective coating, per lens

V2755 U-V lens, per lens

V2756 Eye glass case

V2760 Scratch resistant coating, per lens

V2761 Mirror coating, any type, solid, gradient or equal, any lens material, per lens

V2762 Polarization, any lens material, per lens

V2780 Oversize lens, per lens

V2781 Progressive lens, per lens

V2782 Lens, index 1.54 to 1.65 plastic or 1.60 to 1.79 glass, excludes polycarbonate, per lens

V2783 Lens, index greater than or equal to 1.66 plastic or greater than or equal to 1.80 glass, excludes polycarbonate, per lens

V2784 Lens, polycarbonate or equal, any index, per lens

V2786 Specialty occupational multifocal lens, per lens

MEDICALLY NECESSARY

SCLERAL COVER

V2627 Scleral shell cover.

Revenue CodesN/A



Version Effective Date: 10/01/2018
Version Issued Date: 10/01/2018
Version Reissued Date: N/A

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Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.