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Medicine
Chapter 7
Section 6.2
Lenses (Intraocular Or Contact)
And Eye Glasses
Issue Date: January 23, 1984
Copyright: CPT
only © 2006 American Medical Association (or such other date of
publication of CPT).
All Rights Reserved.
Revision: C-1, March 10, 2017
1.0 CPT
PROCEDURE CODES
92310 - 92326
2.0 POLICY
2.1 Lenses
must be
either approved for marketing by the U.S.
Food and Drug Administration (FDA)
or subject to an
Investigational Device Exemption (IDE).
See Chapter 8, Section 5.1.
2.2 Lenses
or eye glasses are only cost-shared for the following conditions:
• Contact
lenses for treatment of infantile glaucoma.
• Corneal or scleral
lenses for treatment of keratoconus.
• Scleral lenses to
retain moisture when normal tearing is not present or is inadequate.
• Corneal or scleral
lenses prescribed to reduce a corneal irregularity other than astigmatism.
• Intraocular lenses (IOL),
contact lenses, or eyeglasses to perform the function of the human lens,
lost as the result of intraocular surgery or ocular injury or congenital
absence. Benefits for the IOL for this condition are
limited to the standard fixed non-accommodating monofocal IOL, (V2630,
V2631, V2632).
2.3 Benefits
are also specifically limited to
one set of
lenses
related to one of the qualifying eye conditions
listed in paragraph 2.2. A set may also include a combination
of both lenses and eyeglasses when a combination is necessary
and
related to one of the qualifying eye conditions.
2.4 When there
is a prescription change still related to the qualifying eye condition,
a new set may be cost-shared, subject to medical review.
2.5 Reimbursement for a standard
monofocal IOL covered under paragraph 2.2 is
packaged into the payment for the extraction and lens implantation
performed in a hospital on either an inpatient basis subject to
the Diagnosis Related Group (DRG) reimbursement system (see the
TRICARE Reimbursement Manual (TRM), Chapter 6, Section 4, paragraph 3.2)
or outpatient basis subject to Outpatient Prospective Payment System
(OPPS) (see the TRM, Chapter 13, Section 3, paragraph 3.6.4.3) or
in an Ambulatory Surgical Center (ASC) (see the TRM, Chapter 6, Section 4, paragraph 3.2).
For a standard monofocal IOL inserted in a physician’s office, payment
for the IOL is based upon the allowable charge basis.
3.0 EXCLUSIONS
3.1 When the
prescription remains unchanged, replacement for lenses that are
lost, have deteriorated or that have become unusable due to physical
growth are not covered.
3.2 Adjustments,
cleaning, or repairs of glasses are not covered (Current Procedural
Terminology (CPT) procedure codes 92340 - 92371).
3.3 Astigmatism-Correcting Intraocular
Lenses (A-C IOL) (V2787) and Presbyopia-Correcting Intraocular Lenses
(P-C IOL) (V2788) are excluded from TRICARE coverage. Any adjustments, subsequent
treatment, services or supplies required to examine and monitor
the beneficiary who receives an A-C IOL or P-C IOL are also excluded.
These items are excluded and the beneficiary is responsible for
costs associated with these excluded lenses.
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