Determination of Refractive State

Overview  
Determination of the refractive state is necessary for obtaining glasses and includes specification of lens type (monofocal, bifocal, other), lens power, axis, prism, absorptive factor, impact resistance and other factors. 

Original Medicare  
Under Original Medicare, determination of refractive state is statutorily excluded from coverage. No payment may be made under Part A or Part B for any expenses incurred for items or services when such expenses are for routine physical checkups, eyeglasses (other than eyewear described in §1861 (s) (8)) or eye examinations for the purpose of prescribing, fitting or changing eyeglasses, or procedures performed during the course of any eye examination to determine the refractive state of the eyes.  

Expenses for all determination of refractive state 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. 

BCBSNE Medicare Advantage Enhanced Benefit  
The Blue Cross and Blue Shield of Nebraska Medicare Advantage plans provide at least the same level of benefit coverage as Original Medicare (Part A and Part B) and may provide enhanced benefits beyond the scope of Original Medicare within a single health care plan. This flexibility allows Blue Cross and Blue Shield of Nebraska (BCBSNE) to offer enriched plans by using Original Medicare as the base program and adding desired benefit options.  

Because Original Medicare does not cover determination of refractive state procedures, the scope of the benefit, reimbursement methodology, maximum allowed payment amounts and member cost-sharing are determined by BCBSNE for individual coverage.  

Determination of refractive state procedures are covered only under these circumstances:

• A provider must identify the member’s refractive state to determine an injury, illness or disease.  
• An ophthalmologist or an optometrist must determine the refractive state for corrective lenses.  
• The member’s refractive state is determined as part of a surgical procedure. 

Conditions for Payment

Reimbursement  
The provider will be paid the lesser of the allowed amount or the provider’s charge, minus the member’s cost share. This represents payment in full and providers are not allowed to balance bill the member for the difference between the allowed amount and the charge. 

Member Cost-sharing 

• BCBSNE Medicare Advantage providers should collect the applicable cost-sharing from the member at the time of the service when possible. Cost-sharing refers to a flat-dollar copayment a percentage coinsurance or a deductible. Providers can only collect the appropriate BCBSNE Medicare Advantage cost-sharing amounts from the member. 
• If the member elects to receive a non-covered service, he or she is responsible for the entire charge associated with the non-covered service.  

To verify benefits and cost share, providers may call 888-505-2022.  

Billing Instructions for Providers 

1. Bill services on the CMS 1500 (02/12) claim form. 
2. Use the BCBSNE Medicare Advantage unique billing requirements.  
3. Report CPT/HCPCS codes and diagnosis codes to the highest level of specificity. 
4. Include your National Provider Identifier number on all claims. 
5. Send your claims to your local BCBS plan. 

Additional Billing Instructions

1. Identify the member’s refractive state to determine an injury, illness or disease  
   1. Evaluation and management codes: general ophthalmological services, office or other outpatient services, office or other outpatient consultation, and emergency department services must be billed along with 92015. Both are payable.  
2. Determine the refractive state for corrective lenses.  
   1. A routine ophthalmological examination, which includes the refraction, must be billed.  
   2. CPT code 90215 cannot be reported as a separate procedure.  
3. Determine if the member’s refractive state is a part of the surgical procedure. For questions related to proper bill coding, you may contact Provider Servicing at 888-505-2022.  
   1. The surgical code must be billed.  
   2. CPT code 90215 is considered incidental or mutually exclusive and cannot be reported. 

Revision History:  
Policy Number: NEHMO 1003 Policy  
Created: 07/18/2016  
Revised: 01/20/2020  
Policy Effective: 01/01/2017