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 recipient’s
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.