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
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.
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).