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Medicare denial of optical services


I've billed 92014 and 92004 for vision exams and am being rejected by Medicare saying that "Payment is adjusted when performed/billed by a provider of this specialty."  Our doctor is an optometrist.

Are these codes incorrect for vision exam?  Are there other codes?  These patients typically have either cataracts or are diabetic.

Thanks, hope someone can help!


Medicare Non-Covered
Routine examinations for the purpose of prescribing, fitting or changing eyeglasses, as well as eye refractions, are not covered by Medicare.  Eye examination claims (CPT-4 codes 92002, 92004, 92012 and 92014) for Medicare/Medi-Cal eligible recipients with only
diagnoses for disorders of refraction, accommodation and color vision
deficiencies may be billed directly to Medi-Cal.  The recipientís
primary ICD-9-CM diagnosis code must be entered in the Diagnosis or Nature of Illness or Injury field (Box 21) of the CMS-1500 claim.

Determination of refractive state (CPT-4 code 92015) is not covered by Medicare and may be billed directly to Medi-Cal.

Refer to the Medicare Non-Covered Services:  CPT-4 Codes section in this manual for a list of ICD-9-CM diagnosis codes that may be billed directly to Medi-Cal for CPT-4 codes 92002, 92004, 92012 and 92014.

Hard Copy Billing   

Claims that do not automatically cross over electronically from Medicare carriers must be hard copy billed to the EDS Crossover Unit on a CMS-1500 claim.  Refer to the Medicare/Medi-Cal Crossover Claims:  Vision Care section in this manual for detailed crossover billing information.

Providers must attach a copy of the Explanation of Medicare Benefits (EOMB)/Medicare Remittance Notice (MRN) to all crossover claims.

  We bill for several OD's and we use the 92004, 92014 codes all the time.  I do not understand why your claims are being denied stating "not covered when performed by this type of provider".  I'm assuming you do have a medical diagnosis since you mentioned cataracts & diabetes.  I would call Medicare and ask why the claim is denying.  It doesn't make sense.  Have you been paid in the past, or have you just started submitting claims to Medicare?

Try calling and see if you get anywhere.  If not, leave another post and we'll try to figure something else out.

Good luck

Well, we figured it out!  It was an NPI issue, basically.

Thanks for everyone's responses!



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