Section 537.3 - Reimbursement for payment to self employed and salaried optome

537.3 Reimbursement for payment to self employed and salaried optometrists, dispensing opticians and retail optical establishments. (a) General information and instructions.

(1) "______" Underlined code numbers indicate that prior approval is required.

(2) The fees listed in the following schedule apply to self-employed and salaried optometrists, dispensing opticians and retail optical establishments. Ophthalmologists cannot bill under these fee codes.

(3) Code number "60020 Disposition fee for undelivered eyeglasses", shall be used only when the recipient fails to pick up his eyeglasses within 60 days following notification that they were ready. Refer to the fee schedule for the appropriate fee.

(4) When billing "by report" the provider must submit with his/her claim form, a statement which indicates the nature, extent, and need for the service; the time, skill and equipment required, including appropriate documentation (e.g., itemized invoice) indicating the total cost of any items or materials, and any other factors which may be pertinent.

(5) Code number "60009" shall be used for home visit services provided to persons in places of residence used as individual's home (including boarding homes, nursing homes, convalescent homes, proprietary homes for adults or for the aged, institutions for the blind, etc.).

(6) "Clinic sessions" (codes 60048, 60049, 60050, 60051), divide the appropriate procedure code fee by the total number of patients (Medicaid and non-Medicaid) in the session. The resulting amount should be claimed from Medicaid for each Medicaid recipient in the session.

(b) Fee schedule for ophthalmic services and materials.

I. SERVICES CODE DESCRIPTION

FEE 60001 Optometric eye examination, complete (NYS Fee

includes tonometry when appropriate); reimbursable to self-employed optometrist only $12.00 60010 Optometric eye examination, complete, by salaried

optometrists (includes tonometry when appropriate) 5.00 60002 Low vision examination; reimbursable to self-employed

optometrist certified to perform low vision examinations 12.00 60013 Low vision follow-up examination (includes fitting of low

vision aid and visual rehabilitation); reimbursable to self-employed optometrist certified to perform low vision examinations 8.00 60008 Visual field examination, complete; reimbursable to selfemployed optometrist only 8.00 60006 Orthoptic evaluation; reimbursable to self-employed

optometrist only 8.00 60007 Orthoptic training (per session); reimbursable to selfemployed optometrist only 4.00 60017 Dispensing fee for first pair or change of single vision

eyeglasses less than .50 diopters 6.00 60018 Dispensing fee for second pair of single vision

eyeglasses 6.00 60044 Dispensing fee for first pair or change of single vision

eyeglasses equal to or greater than .50 diopters 6.00 60045 Dispensing fee for multivision eyeglasses, equal to or

greater than .50 diopters 10.00 60053 Dispensing fee for replacement of lost or destroyed single

vision eyeglasses 6.00 60054 Dispensing fee for replacement of lost or destroyed

multivision eyeglasses 10.00 60020 Disposition fee for undelivered eyeglasses 4.00 60004 Adjustments rendered by other than original

provider 2.00 60005 Repair fee for each unit (repair of or replacement

of each temple or pair of temples, frame or each lens) 2.00 60014 Fitting of hearing aid temples 5.00 60009 Home visit for fitting or adjustments, per visit,

regardless of the number of patients seen 5.00 60043 Mileage, per mile, one way, beyond 10-mile radius

of point of origin (office or home) .50 60023 Fitting of corneal hard contact lenses, pair (includes

materials); for ocular pathology with the recommendation of an ophthalmologist 100.00 60024 Fitting of corneal hard contact lenses, pair (includes

materials); for ocular pathology, with the recommendation of an ophthalmologist 150.00 60025 Replacement of corneal hard contact lens (includes

materials); for ocular pathology, with the recommendation of an ophthalmologist 35.00 60026 Fitting of scleral hard contact lens, single (includes

materials); for ocular pathology, with the recommendation of an ophthalmologist 125.00 60027 Fitting of scleral hard contact lenses, pair (includes

materials); for ocular pathology, with the recommendation of an ophthalmologist 200.00 60028 Replacement of scleral contact lens (includes materials);

for ocular pathology, with the recommendation of an ophthalmologist 45.00 60029 Fitting of corneal soft contact lens, single (includes

materials); for ocular pathology, with the recommendation of an ophthalmologist 150.00 60030 Fitting of corneal soft contact lenses, pair (includes

materials); for ocular pathology, with the recommendation of an ophthalmologist 250.00 60031 Replacement of corneal soft contact lens (includes

materials); for ocular pathology, with the recommendation of an ophthalmologist 65.00 60032 Cleaning and polishing contact lens 8.00 60040 Fitting of artificial eye, stock (includes materials);

for ocular pathology, with the recommendation of an ophthalmologist 50.00 60041 Fitting of artificial eye, custom made (includes

materials); for ocular pathology, with the recommendation of an ophthalmologist By Report 60042 Cleaning and polishing artificial eye 8.00 60048 Clinic, one-hour session; reimbursable to self-employed

optometrists only 15.00 60049 Clinic, two-hour session; reimbursable to self-employed

optometrists only 25.00 60050 Clinic, three-hour session; reimbursable to self-employed

optometrist only 35.00 60051 Clinic session, each additional hour (per hour);

reimbursable to self-employed optometrists only 7.00 60099 Unlisted eye service By Report

II. MATERIALS CODE DESCRIPTION

FEE PER LENS

FINISHED STOCK LENSES

(Meeting F.D.A. Regulations and Finished into Frame)

SPHERES: (+ or -) 60113 Plano to 10.00 D $ 4.65

COMPOUNDS: (+ on + or - on +) 60123 Plano to 8.00 DS: 0.25 DC to 4.00 DC 5.35

BIFOCALS: (+ or -) 60411 Kryptok 6.00 60412 Flat Top 7.00 60413 Twinsite 6.50

SURFACED SINGLE VISION LENSES

(Meeting F.D.A. Regulations and Finished into Frame)

SPHERES:(+ or -) 60213 Plano to 7.00D 6.00 60214 7.25 D to 18.00D 7.75 60216 18.25 D or higher By Report

COMPOUNDS: (+ on - or - on -) 60223 Plano to 7.00DS; 0.25 DC to 4.00 DC 6.80 60224 7.25 DS to 18.00 DS; 0.25 DC to 4.00DC 8.55 60226 18.25 DS or higher; 0.25 DC to 4.00DC By Report

ADDITIONS: 60313 Plastic Spheres: Plano to 18.00 D .80 60323 Plastic Compounds: Plano to 18.00 D .85 60331 Cylinders: 4.25 D to 6.00 D 1.75 60332 Cylinders: 6.25 D and over By Report 60362 Plano Base 8.00 60371 Hi-Lite 4.25

SURFACED KRYPTOK BIFOCALS

(Meeting F.D.A Regulations and Finished into Frame)

SPHERES: (+ or -) 60513 Plano to 7.00D 8.05 60514 7.25 D to 18.00D 9.80 60516 18.25 D or higher By Report

COMPOUNDS: (+ on - or - on -) 60523 Plano to 4.00 DS; 0.24 DC to 4.00 DC 9.00 60524 4.25 DS to 18.00 DS; 0.25 DC to 4.00 DC 10.75 60526 18.25 DS or higher (plastic only - See Additions);

0.25 DC to 4.00 DC By Report

ADDITIONS 60613 Plastic Spheres: Plano to 7.00 D 2.15 60614 Plastic Spheres: 7.25 D to 18.00 D 2.85 60616 Plastic Spheres: 18.25 D or higher By Report 60623 Plastic Compounds: Plano to 4.00 DS; 0.25 DC to

4.00 DC 2.15 60624 Plastic Compounds: 4.25 DS to 18.00 DS; 0.25 DC

to 4.00 DC 3.05 60626 Plastic Compounds: 18.25 DS or higher;

0.25 DC to 4.00 DC By Report 60631 Cylinders: 4.25 to 6.00D 2.10 60632 Cylinders: 6.25 D and over By Report 60642 Flat Top 22-25 and Executive 3.00 60643 Flat Top 28, 35, Ultex A, Ultex B, or No Krome By Report 60653 Additions over 4.00 D: Glass or Plastic By Report 60663 Special Base Curves 8.00 60692 Trifocal-Flat Top or Executive By Report

APHAKIC LENSES

(Meeting F.D.A. Regulations and Finished into Frame) 60711 Single Vision - Lenticular - Spheres 20.00 60721 Single Vision - Lenticular - Compounds 22.20 60712 Single Vision - Full Field - Aspheric - Spheres 21.65 60722 Single Vision - Full Field - Aspheric - Compounds 23.80 60713 Balance Lens 10.05 60715 Temporary Aphakic Eyeglasses - Complete 10.50 60731 Bifocal - Lenticular - Spheres or Compounds 30.70 60732 Bifocal - Full Field - Aspheric - Spheres or Compounds 35.80

OTHER LENS ADDITIONS

(Meeting F.D.A. Regulations and Finished into Frame)

Special Lens Forms - Glass or Plastic 60802 Double Concave or Convex 8.00 60804 Myodisc or Lenticular "G" 8.00 60821 Tinted, Coated or Dyed Lens 1.90 60831 Prism; 0.25 and over for plastic; 3.25 and

over for glass 1.50 60841 Slab Off 11.00 60842 Frosted Lens 1.50

FRAMES 60911 Zyl Frame and Case 6.00 60912 Adjustable Pad Frame and Case 6.50 60913 Zyl Front 2.00 60914 Zyl Temple 1.00

MISCELLANEOUS 60922 Hand Magnifier 4.00 60923 Plastic Occluder 1.00 60924 Press-on Prism 0.25 to 30 9.00 60999 Unlisted Materials By Report

LOW VISION AIDS

Reimbursable to self-employed optometrist certified

to perform low vision examination 60931 Clear Image: Telescopes 2.2X, two lenses plus correction

lenses and one or more reading caps 284.00 60932 Clear Image: One telescope including balance lens,

correction lens and one or more reading caps 215.00 60933 Bioptic: Telescopes 2.2X or 3X, two lenses including

correction lenses and one or more reading caps 352.00 60934 Bioptic: One telescope including balance lens, correction

lens and one reading cap 228.00 60935 Trioptic: Telescopes plus microscopes, two lenses

including correction lens 461.00 60936 Trioptic: One lens, telescope plus microscope and balance

lens 317.00 60939 Kollmorgan: One telescope including reading cap plus

balance lens 215.00 Clear Image: Microscope 3X to 20X, plus balance lens 151.00 Bifocal Microscope: One Microscope Lens 2X to 20X including dummy lens and 2 carrier lenses plus frame and case 210.00 Hand held telescope 20.00 Aleo-type clip on near telescope, 3.5X 35.00 Telesight + 3.00 to + 8.00 25.00 Microscopic Plastic Prism Spectacles 54.00 Aspheric Microscope (Plastic) 59.00 Cataract Aspheric Hand Magnifier 13.00

 

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