Determination of Refractive State

Reimbursement Policy:
Determination of Refractive State

Effective Date:
November 16, 2015

Purpose: 
Provide guidelines for reimbursement of determination of refractive state under medical benefits when performed by a provider that has a phoropter available to perform the services, such as an ophthalmologist or an optometrist, and it is performed for conditions related to diseases of the eye.

Scope:

• All products are included, except
• Products where Horizon BCBSNJ is secondary to Medicare (e.g. Medigap).
• COB
• ITS Home

All Insured and Administrative Services Only (ASO) accounts are included.

Definitions:
CPT® code 92015 - Using a phoropter to determine the refractive power of the eyes

Phoropter – Ophthalmic testing device used by eye care professionals during an eye exam that contains different lenses used for refraction of the eye during sight testing.

Policy: 
Claims for a determination of refractive state submitted with CPT Code 92015 will be covered by Horizon BCBSNJ under medical benefits when performed by an Ophthalmologist or an Optometrist for conditions related to diseases of the eye.*

Horizon BCBSNJ will no longer reimburse providers other than an Ophthalmologist and Optometrist for these services unless the provider advises that they possess the necessary phoropter equipment and will continue to limit eligibility to conditions referenced above under medical benefits.

Please note: Determination of refractive state (92015) differs from the Snellen/Eye Chart vision test. 92015 is not the appropriate code to use when rendering the Snellen/Eye Chart vision test. Providers who are rendering the Snellen/Eye Chart test should use the appropriate code (99173) when submitting claims.

Procedure:
Horizon BCBSNJ will initially deny claims under medical benefits for code 92015 when billed as follows:

• by a provider other than an ophthalmologist and optometrist.**
• by an ophthalmologist or optometrist for routine screening exams not related to diseases of the eye

Please note: Use of a phoropter by an Optometrist/Ophthalmologist for conditions not related to diseases of the eye may be eligible for reimbursement under the member’s vision benefits.

In denied instances where the provider is participating, there shall be no member liability.

In denied instances where the provider is non-participating, the member’s liability shall be up to the provider’s charge.

Limitations and Exclusions:

• While reimbursement is considered, payment determination is subject to, but not limited to:
• Group or Individual benefit
• Provider Participation Agreement
• Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity
• Mandated or legislative required criteria will always supersede.

*Any provider other than an ophthalmologist or an optometrist who performs a refraction test using a phoropter billed using CPT code 92015, and whose claim is denied as a result of this Policy, may submit an appeal supported with medical records that reflect the use of a phoropter to determine the patient’s refractive state.