Medicare Fee-For-Service/ original Medicare does not normally cover routine vision services, such as eyeglasses and eye exams. Medicare may cover some vision costs associated with eye problems resulting from an illness or injury. This article covers Medicare-covered vision services for certain beneficiaries, including Intraocular lenses (IOLs); Glaucoma screenings and other Medicare-covered services. Generally, Medicare covers items or services if they satisfy three basic requirements. The item or service must:
- Fall within a statutorily defined benefit category
- Be reasonable and necessary for the diagnosis or treatment of illness or injury, or to improve the functioning of a malformed body part
- Not be excluded from coverage
Intraocular lenses (IOLs)
A conventional IOL is a small, lightweight, clear disk that replaces the focusing power of the eye’s natural crystalline lens. Medicare covers a conventional IOL when it is implanted as part of cataract surgery. A cataract is an opacity or cloudiness in the crystalline lens of the eye blocking the passage of light through the lens, sometimes resulting in blurred or impaired vision. Medicare specifically excludes certain items and services from coverage, including eyeglasses and contact lenses. Medicare does cover the following IOL items and services:
- A conventional IOL implanted during cataract surgery
- Facility and physician services and supplies required to insert a conventional IOL during cataract surgery
- One pair of eyeglasses or contact lenses as a prosthetic device furnished after each cataract surgery with an IOL insertion (Note: Durable Medical Equipment (DME) suppliers billing for eyeglasses or contact lenses should submit claims to DME MAC)
Presbyopia- and Astigmatism-Correcting IOLs
Presbyopia and astigmatism are common eye problems corrected by presbyopia-correcting IOLs (P-C IOLs) and astigmatism-correcting IOLs (A-C IOLs). A P-C IOL or A-C IOL provides what is otherwise achieved by two separate items or services:
- An implantable conventional IOL (one that is not P-C or A-C) that Medicare covers, and
- The surgical correction, eyeglasses, or contact lenses to correct presbyopia or astigmatism that Medicare does not cover
When a beneficiary requests a P-C or A-C IOL instead of a conventional IOL, inform the beneficiary before the procedure that Medicare does not pay for the physician and facility services specific to the insertion, adjustment, or other subsequent treatments that are attributable to the functionality of the P-C or A-C IOLs.
While billing, you must report the appropriate HCPCS code for P-C or A-C IOLs even though Medicare does not cover that part of the service. We have listed the approved Current Procedural Terminology (CPT) and HCPCS codes for cataract removal and IOL insertion. Please note that Cataract removal codes are mutually exclusive and billed only once per eye.
Approved codes for Cataract Removal, P-C IOLs, and A-C IOLs: 66830; 66840; 66850; 66852; 66920; 66930; 66940; 66982; 66983; 66984; V2632; V2787 and V2788.
A covered glaucoma screening includes a dilated eye examination with an intraocular pressure measurement; a direct ophthalmoscopy examination, or a slit-lamp biomicroscopic examination. Medical record documentation must show the beneficiary is a member of one of the high-risk groups. The documentation must also show you performed the covered screening services. Include diagnosis code Z13.5 on your claim.
Approved codes: G0117 (Glaucoma screening for high-risk patients furnished by an optometrist or ophthalmologist); G0118 (Glaucoma screening for high-risk patient furnished under the direct supervision of an optometrist or ophthalmologist)
Other Covered Services
- Eye prostheses for patients with absence or shrinkage of an eye due to a birth defect, trauma, or surgical removal. Medicare generally covers replacement every 5 years. Medicare covers polishing and resurfacing. (DME suppliers billing for eyeglasses or contact lenses should submit claims to their DME MAC)
- Eye exams to evaluate for eye disease for patients with diabetes or signs and symptoms of eye disease. Annual examinations by an ophthalmologist or optometrist are recommended for asymptomatic diabetics.
- Certain diagnostic tests and treatments for patients with age-related macular degeneration.