TRICARE Manuals - Display Chap 7 Sect 6.1 (Change 61, Apr 17, 2020)

Medicine

Chapter 7

Section 6.1

Ophthalmological Services

Issue Date: November 3, 1992

Authority: 32 CFR 199.4(c)(2)(xvi), (e)(6), (g)(46), (g)(50), and 10 USC 1079(a)(3)

Revision: C-61, April 17, 2020

1.0 CPT PROCEDURE CODE RANGES

92002 - 92060, 92070 - 92335, 92390 - 92499

2.0 DESCRIPTION

Ophthalmological services may include an examination and other specialized services. The purpose of an examination is to diagnose or treat a medical condition of the eye, eyelid, lacrimal system, or orbit. A “routine eye examination” is an evaluation of the eyes, including but not limited to refractive services, that is not related to a medical or surgical condition or to the medical or surgical treatment of a covered illness or injury.

3.0 POLICY

3.1 For all beneficiaries, ophthalmological services (including refractive services) provided in connection with the medical or surgical treatment of a covered illness or injury are covered.

3.2 For Active Duty Family Members (ADFMs) payment can be made for one routine eye examination per year.

3.2.1 Routine eye examinations as defined in 32 CFR 199.2 includes coverage of those services rendered in order to determine the refractive state of the eyes. The Current Procedural Terminology (CPT) procedure codes for payment of routine eye examinations are as follows:

92002 - EYE EXAM, NEW PATIENT

92004 - EYE EXAM, NEW PATIENT

92012 - EYE EXAM, ESTABLISHED PATIENT

92014 - EYE EXAM & TREATMENT

92015 - REFRACTION

99172 - OCULAR FUNCTION SCREEN

99173 - VISUAL ACUITY SCREEN

3.2.2 TRICARE Prime and Standard (through December 31, 2017) and TRICARE Select (starting January 1, 2018) ADFMs are entitled to one annual routine eye examination. Prime ADFMs may receive their annual routine eye examination from any network provider without referral, authorization, or preauthorization from the Primary Care Manager (PCM), or any other authority; i.e., a Prime ADFM will be allowed to set up his or her own appointment for a routine eye examination with any network optometrist or ophthalmologist. Standard (through December 31, 2017) and TRICARE Select (starting January 1, 2018) ADFMs may self-refer to any TRICARE authorized provider regardless of whether or not they are a network provider; i.e., they may set up his or her own appointment with either a network or non-network, TRICARE authorized, optometrist or ophthalmologist.

3.3 For Prime enrollees, see Section 2.2 for additional information on routine eye examinations.

3.4 Heidelberg Retina Tomograph (HRT), and Scanning laser polarimetry (GDx) (CPT procedure code 92135) to diagnose and monitor progression of suspected glaucoma may be considered for cost-sharing. Optical Coherence Tomograph (OCT) to diagnose and monitor progression of suspected retinal disease may be considered for cost-sharing. Effective October 28, 2008.

3.5 Vision home monitoring with preferential hyperacuity perimetry (ForeseeHome™ Monitoring Device) (CPT procedure codes 0378T-0380T) to monitor the progression of intermediate or advanced age-related macular degeneration in patients 65 years of age or older, may be considered for cost-sharing. Effective November 11, 2013.

4.0 Related TRICARE Policies

For reimbursement of instrument-based vision screenings for children age one to age six when provided by a physician other than an ophthalmologist or optometrist as part of a well-child care program, see Section 2.5.

5.0 EXCLUSIONS

5.1 Routine eye examinations are NOT covered for Standard (through December 31, 2017)/TRICARE Select (starting January 1, 2018) retirees or their dependents that are not enrolled in Prime except for eye exams allowed under the well-child benefit in Section 2.5.

5.2 Orthoptics, also known as vision training, vision therapy, eye exercises, eye therapy, is excluded by 32 CFR 199.4(g)(46) (CPT procedure code 92065).

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