§ 51518. Optometry Services.

(a) General Provisions.

(1) The reimbursement for optometric services shall be in accordance with the maximum reimbursement rates listed below; however, billing shall not exceed charges made to the general public.

(2) Additional routine tests that may be needed shall be considered a part of the basic examination. Extensive treatment programs or difficult tests not included in the list below may be billed as unlisted items.

(3) Maximum allowances include preparation of necessary forms when an eye appliance is prescribed.

(4) Procedure Codes 92004, 92012 and 92014 are from the “Physicians' Current Procedural Terminology” Fourth Edition, 1990, (CPT-4), which is hereby incorporated by reference. Providers shall use all related guidelines and criteria listed in the 1990 CPT-4, as adopted by the Department, to bill for these CPT-4 procedure codes.

(b) Maximum reimbursement allowances for optometry services shall be as follows:

(1) Diagnostic and Ancillary Procedures.

Procedure		Maximum
Code		Rate
92002	Optometric service; medical examination and
	evaluation with initiation of diagnostic and
	treatment program, intermediate, new patient	$32.80
92004	Optometric service; comprehensive, new patient,
	one or more visits. (To include case history, visual
	acuity testing, opthalmoscopy, ocular motility
	testing, testing for neurological integrity, refraction
	at far and near points, phorometric tests,
	confrontation fields and tonometry)	47.45
92012	Optometric service, medical examination
	and evaluation, with initiation or
	continuation of diagnostic and treatment program;
	intermediate, established patient (seen within six
	months of the comprehensive examination)	22.59
92014	Optometric service; comprehensive, established
	patient, one or more visits. (To include case history,
	visual acuity testing, ophthalmoscopy, ocular
	motility testing, testing for neurological integrity,
	refraction at far and near points, phorometric tests,
	confrontation fields and tonometry)	47.45
92020	Gonioscopy (separate procedure)	16.40
92081	Visual field examination, unilateral or bilateral,
	with interpretation and report; limited examination
	(eg, tangent screen, Autoplot, arc perimeter, or
	single stimulus level automated test,
	such as Octopus 3 or 7 or equivalent)	16.40
92082	Visual field examination, unilateral or bilateral,
	with interpretation and report; intermediate
	examination (eg, at least 2 isopters on Goldman
	perimeter, or semiquantitative, automated
	suprathreshold screening program, Humphrey
	suprathreshold automatic diagnostic test,
	Octopus program 33)	22.14
92083	Visual field examination, unilateral or bilateral,
	with interpretation and report; extended
	examination, (eg, Goldmann visual fields
	with at least 3 isopters plotted and static
	determination within the central 30 <<degrees>>, or
	quantitative, automated threshold perimetry,
	Octopus program G-1, 32 or 42, Humphrey
	visual field analyzer full threshold programs
	30-2, 24-2, or 30/60-2)	22.14
92100	Serial tonometry (separate procedure) with multiple
	measurements of intraocular pressure over an extended
	time period with interpretation and report, same day
	(eg, diurnal curve or medical treatment of acute elevation
	of intraocular pressure)	28.93
92225	Ophthalmoscopy, extended, with retinal drawing
	(eg, for retinal detachment, melanoma), with
	interpretation and report, initial	41.00
92250	Fundus photography with interpretation and report	42.13
99201	Office or other outpatient visit for the evaluation and
	management of a new patient, which requires these
	three key components: a problem focused history;
	a problem focused examination; and straightforward
	medical decision making	11.41
99202	Office or other outpatient visit for the evaluation
	and management of a new patient, which requires these
	three key components: an expanded problem focused
	history; an expanded problem focused
	examination; and straightforward medical decision
	making	34.30
99203	Office or other outpatient visit for the evaluation
	and management of a new patient, which requires these
	three key components: a detailed history; a detailed
	examination; and medical decision making of low
	complexity	57.20
99204	Office or other outpatient visit for the evaluation
	and management of a new patient, which requires these
	three key components: a comprehensive history; a
	comprehensive examination; and medical decision making
	of moderate complexity	68.90
99205	Office or other outpatient visit for the evaluation
	and management of a new patient, which requires these
	three key components: a comprehensive history; a
	comprehensive examination; and medical decision making
	of high complexity	82.70
99211	Office or other outpatient visit for the evaluation
	and management of an established patient, that may
	not require the presence of a physician	12.00
99212	Office or other outpatient visit for the evaluation
	and management of an established patient, which
	requires at least two of these three key components:
	a problem focused history; a problem focused
	examination; and straightforward medical decision
	making	11.41
99213	Office or other outpatient visit for the evaluation
	and management of an established patient, which requires
	at least two of these three key components: an expanded
	problem focused history; an expanded problem
	focused examination; medical decision making of low
	complexity	24.00
99214	Office or other outpatient visit for the evaluation
	and management of an established patient, which requires
	at least two of these three key components: a detailed history;
	a detailed examination; medical decision making of
	moderate complexity	37.50
99215	Office or other outpatient visit for the evaluation
	and management of an established patient, which requires
	at least two of these three key components: a comprehensive
	history; a comprehensive examination; medical decision
	making of high complexity	57.20
99241	Office consultation for a new or established patient,
	which requires these three key components: a problem
	focused history; a problem focused examination; and
	straightforward medical decision making	30.60
99242	Office consultation for a new or established patient,
	which requires these three key components: an expanded
	problem focused history; an expanded problem focused
	examination; and straightforward medical decision
	making	47.20
99243	Office consultation for a new or established patient,
	which requires these three key components: detailed
	history; a detailed examination; and medical decision
	making of low complexity	59.50
(2) Supplemental Procedures
65205	Removal of foreign body, external eye;
	conjunctival superficial	$6.74
65210	Removal of foreign body, external eye; conjunctival
	embeddeed (includes concretions), subconjunctival,
	or scleral nonperforating	117.27
65220	Removal of foreign body, external eye;
	corneal, without slit lamp	13.48
65222	Removal of foreign body, external eye;
	corneal, with slit lamp	20.21
67820	Correction of trichiasis; epilation, by forceps only	13.48
67938	Removal of embedded foreign body, eyelid	273.27
68761	Closure of the lacrimal punctum; by plug, each	125.47
68801	Dilation of lacrimal punctum, with or without irrigation	136.63
Z2700	Low vision patient. To include professional
	evaluation, fitting and subsequent supervision,
	including six months' follow-up care	75.11
Z2704	Detailed biomicroscopy/slit lamp evaluation	9.88
Z2706	Contact lens examination (in addition to
	basic examination) to include multiple
	ophthalmometry, measurement of tear flow,
	measurement of ocular adnexa, initial
	tolerance evaluation, and other tests as
	necessary	33.05
Z2708	Out-of-office call (add to procedure allowance)	7.50
Z2710	Mileage -per mile one way beyond a ten-mile
	radius from point of origin	1.36
Z2712	Diagnostic closure of the lacrimal punctum;
	by absorbable plug, 1 or more closures;
	includes office visits	48.84
92499	Unlisted procedure	By Report

HISTORY

1. Amendment of subsection (b) filed 8-1-84 as an emergency; effective upon filing (Register 84, No. 31). A Certificate of Compliance must be transmitted to OAL within 120 days or emergency language will be repealed on 11-29-84. For prior history, see Register 81, No. 52.

2. Certificate of Compliance transmitted to OAL 11-27-84 and filed 12-27-84 (Register 84, No. 52).

3. Amendment of subsection (b) filed 8-1-85 as an emergency; effective upon filing (Register 85, No. 32). A Certificate of Compliance must be transmitted to OAL within 120 days or emergency language will be repealed upon 11-29-85.

4. Certificate of Compliance transmitted to OAL 11-20-85 and filed 12-27-85 (Register 85, No. 52).

5. Amendment of subsection (b)(2) filed 10-20-86; effective thirtieth day thereafter. Statutes of 1984, Chapter 258, Items 4260-106-001 and 890, and Statutes of 1985, Chapter III, Items 4260-106-001 and 890 (Register 86, No. 43).

6. Repealer and new section filed 9-25-92 as an emergency; operative 10-1-92 (Register 92, No. 40). A Certificate of Compliance must be transmitted to OAL 1-25-93 or emergency language will be repealed by operation of law on the following day.

7. Certificate of Compliance as to 9-25-92 order transmitted to OAL 1-22-93 and filed 3-9-93 (Register 93, No. 11).

8. Amendment of subsections (b)(1) and (b)(2) filed 7-21-98; operative 7-27-98 pursuant to Government Code section 11343.4(d) (Register 98, No. 30).

9. Amendment of subsection (a)(4) filed 7-21-98 as an emergency; operative 7-27-98 (Register 98, No. 30). A Certificate of Compliance must be transmitted to OAL by 11-24-98 or emergency language will be repealed by operation of law on the following day.

10. Editorial correction of History 9 (Register 99, No. 2).

11. Certificate of Compliance as to 7-21-98 order transmitted to OAL 11-23-98 and filed 1-7-99 (Register 99, No. 2).

12. Amendment of subsection (b)(1) and amendment of Note filed 11-13-2000 as an emergency; operative 11-13-2000 (Register 2000, No. 46). A Certificate of Compliance must be transmitted to OAL by 3-13-2001 or emergency language will be repealed by operation of law on the following day.

13. Certificate of Compliance as to 11-13-2000 order transmitted to OAL 3-13-2001 and filed 4-4-2001 (Register 2001, No. 14).

14. Amendment of subsections (b)(1)-(2) and amendment of Note filed 12-19-2001 as an emergency; operative 12-19-2001 (Register 2001, No. 51). A Certificate of Compliance must be transmitted to OAL by 4-18-2002 or emergency language will be repealed by operation of law on the following day.

15. Certificate of Compliance as to 12-19-2001 order transmitted to OAL 4-9-2002 and filed 4-30-2002 (Register 2002, No. 18).

Note

Note: Authority cited: Sections 10725, 14105 and 14124.5, Welfare and Institutions Code. Reference: Section 14105, Welfare and Institutions Code; Statutes of 1999, Chapter 50, Items 4260-101-0001 and 0890; and Sections 11024, 11026, 11150 and 11210, Health and Safety Code.