Covered vision procedures are identified by the CPT or HCPCS procedure codes and modifiers listed in the interactive maximum allowable fee schedule. Not all procedure codes indicated in the maximum allowable fee schedules are necessarily covered for every member. The member’s plan (Medicaid, BadgerCare Plus Standard Plan, BadgerCare Plus Benchmark Plan, or BadgerCare Plus Core Plan) also determines the services that are covered for the member. Providers may use the maximum allowable fee schedule in conjunction with the member’s plan to determine if a procedure is covered for the member. Maximum allowable fee information is updated routinely.
CPT or HCPCS procedure codes are required on all 1500 Health Insurance claim forms for vision services. Vision claims without CPT or HCPCS procedure codes are denied.
Optometrists and ophthalmologists may be reimbursed for services related to the dispensing and repair of vision materials, as well as for covered diagnostic and surgical services. Optometrists must have a TPA certificate to be reimbursed for certain surgical procedures as indicated in the tables.
Opticians may be reimbursed for services pertaining to the supply, dispensing, and repair of vision materials.
Ophthalmologists also may be reimbursed for procedure codes listed within the physician service area.
Please note that the CPT and HCPCS procedure codes in the following tables have additional limitations not indicated in these tables, such as POS limitations or PA requirements.
| Provider Types | |
|---|---|
| Code | Description |
| 31 and 33 | Ophthalmologists, ophthalmologist groups, physicians, physician clinics |
| 75 | Federally Qualified Health Centers |
| 18 | All optometrists (including optometrists with a TPA certificate) |
| 18* | Only optometrists with a TPA certificate |
| 19 | Opticians |
| Modifiers | |
|---|---|
| Code | Description |
| 50 | Bilateral procedure |
| 54 | Surgical care only |
| 55 | Postoperative management only |
| E1 | Upper left, eyelid |
| E2 | Lower left, eyelid |
| E3 | Upper right, eyelid |
| E4 | Lower right, eyelid |
| RP | Replacement and repair |
| SC | Medically necessary service or supply |
| U1 | Transitions lens, single vision |
| U2 | Transitions lens, multifocal |
| U4 | High index, multifocal |
| U5 | Changed prescription, single |
| U6 | Changed prescription, bifocal or multifocal |
| U7 | Frame replacement, dispensing fee |
| U8 | Temple replacement, dispensing fee |
| U9 | Lens replacement, changed prescription |
| CPT Procedure Codes | Description | Allowable Modifiers | Allowable Provider Types |
|---|---|---|---|
| 65205-65222 | Eyeball; Removal of Foreign Body | 31 and 33, 75, 18* | |
| 65430-65436 | Anterior Segment; Cornea | 31 and 33, 75, 18* | |
| 66820-66984 | Anterior Segment; Lens | 54, 55 | 31 and 33, 75, 18* |
| 67221 | Posterior Segment; Retina or Choroid | 50 | 31 and 33, 75, 18 |
| 67820-67825 | Ocular Adnexa; Eyelids | 31 and 33, 75, 18 | |
| 67938 | Removal of embedded foreign body, eyelid | 31 and 33, 75, 18* | |
| 68761 | Closure of the Lacrimal punctum; by plug, each | 50 (both lower eyelids), E1, E2, E3, E4 | 31 and 33, 75, 18* |
| 68840 | Probing of Lacrimal canaliculi, with or without irrigation | 31 and 33, 75, 18* | |
| 76510-76529 | Diagnostic Ultrasound; Head and Neck | 31 and 33, 75, 18 | |
| 92002 - 92014 | Ophthalmology; General Ophthalmological Services | 31 and 33, 75, 18 | |
| 92015-92286 | Ophthalmology; Special Ophthalmological Services | 31 and 33, 75, 18 | |
| 92310-92326 | Ophthalmology; Contact Lens Services | 31 and 33, 75, 18, 19 | |
| 92340-92353 | Ophthalmology; Spectacle Services (including prosthesis for aphakia) | RP, U5, U6, U9 | 31 and 33, 75, 18, 19 |
| 92354-92371 | Ophthalmology; Spectacle Services (including prosthesis for aphakia) | 31 and 33, 75, 18, 19 | |
| 92499 | Unlisted Ophthalmological service or procedure | 31 and 33, 75, 18 | |
| 92531-92534 | Special Otorhinolaryngologic Services; Vestibular Function Tests, with Observation and evaluation by Physician, without Electrical Recording | 31 and 33, 75, 18 | |
| 99000 | Handling and/or conveyance of specimen for transfer from the physician's [or optometrist's] office to a laboratory | 31 and 33, 75, 18 | |
| 99201-99205 | Office or Other Outpatient Services; New Patient | 31 and 33, 75, 18 | |
| 99211-99215 | Office or Other Outpatient Services; Established Patient | 31 and 33, 75, 18 | |
| 99221-99223 | Hospital Inpatient Services; Initial Hospital Care | 31 and 33, 75, 18 | |
| 99231-99233 | Hospital Inpatient Services; Subsequent Hospital Care | 31 and 33, 75, 18 | |
| 99241-99245 | Consultations; Office or Other Outpatient Consultations | 31 and 33, 75, 18 | |
| 99251-99255 | Consultations; Initial Inpatient Consultations | 31 and 33, 75, 18 | |
| 99281-99285 | Emergency Department Services | 31 and 33, 75, 18 | |
| 99304-99306 | Nursing Facility Services; Initial Nursing Facility Care | 31 and 33, 75, 18 | |
| 99307-99310 | Nursing Facility Services; Subsequent Nursing Facility Care | 31 and 33, 75, 18 | |
| 99318 | Evaluation and management of a patient involving an annual nursing
facility assessment, which requires these three key components:
|
31 and 33, 75, 18 | |
| 99324-99328 | Domiciliary, Rest Home, or Custodial Care Services; New Patient | 31 and 33, 75, 18 | |
| 99334-99337 | Domiciliary, Rest Home, or Custodial Care Services; Established Patient | 31 and 33, 75, 18 | |
| 99341-99343 | Home Services; New Patient | 31 and 33, 75, 18 |
| HCPCS Procedure Codes | Description | Allowable Modifiers | Allowable Provider Types |
|---|---|---|---|
| A4263 | Permanent, long term, non-dissolvable Lacrimal duct implant, each | 75, 18 | |
| G0117 | Glaucoma screening for high risk patients furnished by an optometrist or ophthalmologist | 31 and 33, 75, 18 | |
| G0118 | Glaucoma screening for high risk patients furnished under the direct supervision of an optometrist or ophthalmologist | 31 and 33, 75, 18 | |
| S0504-S0510 (For requesting PA only) | Safety lenses | SC | 31 and 33, 75, 18, 19 |
| S0516 (For requesting PA only) | Safety glass frames | SC | 31 and 33, 18, 19 |
| V2020 | Frames, purchases | SC, U4, U7, U8 | 31 and 33, 75, 18, 19 |
| V2100-V2118 | Vision Services; Single Vision, Glass or Plastic | SC, U1 | 31 and 33, 75, 18, 19 |
| V2121 | Lenticular lens, per lens, single | 19 | |
| V2199 | Not otherwise classified, single vision lens | SC, U1 | 31 and 33, 75, 18, 19 |
| V2200-V2219 | Vision Services; Bifocal, Glass or Plastic | SC, U2 | 31 and 33, 75, 18, 19 |
| V2220 | Bifocal add over 3.25d | SC, U2 | 31 and 33, 75, 18, 19 |
| V2221 | Lenticular lens, per lens, bifocal | SC | 19 |
| V2299 | Specialty bifocal (by report) | SC, U2 | 31 and 33, 75, 18, 19 |
| V2300-V2320 | Vision Services; Trifocal, Glass or Plastic | SC, U2 | 31 and 33, 75, 18, 19 |
| V2321 | Lenticular lens, per lens, trifocal | SC | 18, 19 |
| V2399 | Specialty trifocal (by report) | SC, U2 | 31 and 33, 75, 18, 19 |
| V2499 | Variable asphericity lens; other type | 31 and 33, 75, 18, 19 | |
| V2500-V2599 | Vision Services; Contact Lenses | 31 and 33, 75, 18, 19 | |
| V2600-V2615 | Vision Services; Low Vision Aids | 31 and 33, 75, 18, 19 | |
| V2623-V2629 | Vision Services; Eye Prosthesis - Prosthetic Eye | 31 and 33, 75, 18, 19 | |
| V2630-V2631 | Vision Services; Intraocular Lenses | 31 and 33, 75, 18, 19 | |
| V2700 | Balance lens, per lens | 19 | |
| V2718 | Press-on lens, fresnell prism, per lens | 31 and 33, 75, 18, 19 | |
| V2744 | Tint, photochromatic, per lens | SC | 31 and 33, 18, 19 |
| V2745 | Addition to lens; tint, any color, solid, gradient or equal, excludes photochromatic, any lens material, per lens | 31 and 33, 18, 19 | |
| V2750 | Anti-reflective coating, per lens | 31 and 33, 75, 18, 19 | |
| V2755 | U-V lens, per lens | SC | 31 and 33, 18, 19 |
| V2762 | Polarization, any lens material, per lens | 18, 19 | |
| V2770 | Occluder lens, per lens | 31 and 33, 75, 18, 19 | |
| V2780 | Oversize lens, per lens | SC | 31 and 33, 18, 19 |
| V2781 | Progressive lens, per lens | SC | 31 and 33, 75, 18, 19 |
| V2782 | Lens, index 1.54 to 1.65 plastic or 1.60 to 1.79 glass, excluding polycarbonate, per lens | 19 | |
| V2783 | Lens, index greater than or equal to 1.66 plastic or greater than or equal to 1.80 glass, excludes polycarbonate, per lens | 19 | |
| V2784 | Lens, polycarbonate or equal, any index, per lens | SC | N/A |
| V2785 | Processing, preserving and transporting corneal tissue | 31 and 33, 75, 18, 19 | |
| V2786 | Specialty occupational multifocal lens, per lens | 18, 19 | |
| V2788 | Presbyopia correcting function of intraocular lens | 18, 19 | |
| V2797 | Vision supply, accessory and/or service component of another HCPCS vision code | 18, 19 | |
| V2799 | Vision service, miscellaneous | SC | 31 and 33, 75, 18, 19 |