Ophthalmology and Optometry Coding Alert

Here's what Medicare will - and won't - cover, and what you can expect from private carriers

Medicare, along with many private health plans, does not cover prescribing and fitting contact lenses for correction of refractive error. In fact, Medicare will usually not cover refractive correction of any kind, including "eyeglasses or contact lenses, and eye examinations for the purpose of prescribing, fitting, or changing eyeglasses or contact lenses for refractive errors," according to Chapter 15 of the Medicare Benefit Policy Manual. "Expenses for all refractive procedures, whether performed by an ophthalmologist (or any other physician) or an optometrist and without regard to the reason for performance of the refraction, are excluded from coverage."

But: Medicare does cover physicians' services to correct eye diseases such as glaucoma or cataracts, as well as "postsurgical prosthetic lenses ... [and] permanent prosthetic lenses required by an individual lacking the organic lens of the eye, whether by surgical removal or congenital disease. Such prosthetic lens is a replacement for an internal body organ - the lens of the eye." You can read the entire Benefit Policy Manual online at www.cms.hhs.gov/manuals/102_policy.

Private carriers: Some insurers, such as Blue Shield of California and Aetna, offer vision riders in addition to their group policies. These plans sometimes cover 100 percent of expenses for ophthalmologic and optometric exams and single-vision lenses, as well as providing an allowance for frames or contact lenses.