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    Routine Vision Exam CPT Codes, Materials HCPCS, and Diagnosis Codes

    Routine vision exam CPT codes, materials HCPCS, and diagnosis codes that should be billed to EyeMed are listed below. Claims submitted to EmblemHealth will be denied.

    CPT Code Description
    92002 Intermediate
    92004 Comprehensive
    92012 Intermediate
    92014 Comprehensive
    92015 Refraction
    V2750 Standard A/R
    V2750-21 A/R Tier 3
    V2750-22 A/R Tier 1
    V2750-25 A/R Tier 2
    V2750-TG Premium A/R
    S0500 Disposable Contact Lenses
    V2500 –V2503 PMMA
    V2510 – V2513 Gas Permeable
    V2520 – V2523 Hydrophilic
    V2530 – V2531 Scleral
    V2599 Other Contact Lenses
    V2020-V2025 Deluxe Frame
    V2700 Balance Lens, Glass or Plastic
    V2702 Edge Treatment (Polish or Roll)
    V2702-TG Faceting
    V2710 Slab-Off Prism
    V2715, V2715U1, V2715U3, V2715U4 Prism
    V2718, V2718U1, V2718U3, V2718U4 Fresnell Prism
    V2730 Special Base Curve
    V2744, V2744U1, V2744U2 Photochromic plastic (Transitions®)
    V2744U5, V2744U6, V2744U7, V2744U8 Photochromic
    V2745, V2745UA, V2745UB, V2745UC Tint, Solid or Gradient
    V2755 UV Lens
    V2760, V2760-22, V2760-TG Scratch-Resistant Coating
    V2761 Mirror Coating
    V2762 Polarization
    V2770 Occluder Lens
    V2780 Oversize Lens
    V2782 Mid-Index (1.56)
    V2783, V2783U1, V2783U3, V2783U4 Hi-Index (1.60+)
    V2100 – V2118, V2410, V2410-22 Single Vision Lens
    V2121, V2221, V2321 Lenticular
    V2200 – V2220, V2299, V2430, V2430-22 Bifocal Lens
    V2300 – V2320, V2399 Trifocal Lens
    V2781 Plans without Fixed Pricing by Tier - Standard Progressive
    V2781 S0581 Premium Progressive - Must include modifier
    V2781 S0581 Progressive Tier 4 - Must include modifier
    V2781-22 Progressive Tier 2
    V2781-25 Progressive Tier 3
    V2781-TG Progressive Tier 1
    V2784 Polycarbonate Standard
    V2784-22 Premium Polycarbonate


    ICD 10 CODES Description
    H52 Disorders of Refraction and Accomodation
    H.52.0 Hyperopia
    H52.00 Hyperopia, unspecfied eye
    H52.01 Hyperopia, right eye
    H52.02 Hyperopia, left eye
    H52.03 Hyperopia, bilateral
    H52.1 Myopia
    H52.10 Myopia, unspecified eye
    H52.11 Myopia, right eye
    H52.12 Myopia, left eye
    H52.13 Myopia, bilateral
    H52.2 Astigmatism
    H52.20 Unspecified astigmatism
    H52.201 Unspecified astigmatism, right eye
    H52.202 Unspecified astigmatism, left eye
    H52.203 Unspecified astigmatism, bilateral
    H52.209 Unspecified astigmatism, unspecified eye
    H52.21 Irregular Astigmatism
    H52.211 Irregular Astigmatism, right eye
    H52.212 Irregular Astigmatism, left eye
    H52.213 Irregular Astigmatism, bilateral
    H52.219 Irregular Astigmatism, unsecified eye
    H52.22 Regular Astigmatism
    H52.221 Regular Astigmatism, right eye
    H52.222 Regular Astigmatism, left eye
    H52.223 Regular Astigmatism, bilateral
    H52.229 Regular Astigmatism, unsecified eye
    H52.31 Anisometropia
    H52.32 Aniseikonia
    H52.4 Presbyopia
    H52.51 Internal ophthalmoplegia
    H52.511 Internal ophthalmoplegia,  right eye
    H52.512 Internal ophthalmoplegia, left eye
    H52.513 Internal ophthalmoplegia, bilateral
    H52.519 Internal ophthalmoplegia, unspecified eye
    H52.52 Paresis of accommodation
    H52.521 Paresis of accommodation, right eye
    H52.522 Paresis of accommodation, left eye
    H52.523 Paresis of accommodation, bilateral
    H52.529 Paresis of accommodation, unspecified  eye
    H52.53 Spasm of accommodation
    H52.531 Spasm of accommodation-right eye
    H52.532 Spasm of accommodation-left eye
    H52.533 Spasm of accommodation-bilateral
    H52.539 Spasm of accommodation-unspecified eye
    H52.6 Other disorders of refraction
    H52.7 Unspecified disorders of refraction
    H53.0 Ambyopia
    H53.00 Unspecified amblyopia
    H53.001 Unspecified amblyopia, right eye
    H53.002 Unspecified amblyopia, left eye
    H53.003 Unspecified amblyopia, bilateral
    H53.009 Unspecified amblyopia, unspecified eye
    H53.01 Deprivation amblyopia
    H53.011 Deprivation amblyopia, right eye
    H53.012 Deprivation amblyopia, left eye
    H53.013 Deprivation amblyopia, bilateral
    H53.019 Deprivation amblyopia, unspecified eye
    H53.02 Refractive amblyopia
    H53.021 Refractive amblyopia, right eye
    H53.022 Refractive amblyopia, left eye
    H53.023 Refractive amblyopia, bilateral
    H53.029 Refractive amblyopia, unspecified eye
    H53.03 Strabismic amblyopia
    H53.031 Strabismic amblyopia-right eye
    H53.032 Strabismic amblyopia-left eye
    H53.033 Strabismic amblyopia-bilateral
    H53.039 Strabismic amblyopia-unspecified eye
    H53.10 Unspecified subjective visual disturbances
    H53.14 Visual Discomfort
    H53.141 Visual Discomfort, right eye
    H53.142 Visual Discomfort, left eye
    H53.143 Visual Discomfort, bilateral
    H53.149 Visual Discomfort, unspecified eye

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    Glossary terms found on this page:

    An activity of EmblemHealth or its subcontractor that results in:

    • Denial or limited authorization of a service authorization request, including the type or level of service
    • Reduction, suspension or termination of a previously authorized service
    • Denial, in whole or in part, of payment for a service
    • Failure to provide services in a timely manner
    • Failure of EmblemHealth to act within the time frames for resolution and notification of determinations regarding complaints, action appeals and complaint appeals

    An itemized statement of health care services and their costs provided by a hospital, physician's office or other health care facility. Claims are submitted to the insurer or managed care plan by either the plan member or the provider for payment of the costs incurred.

    The group of individuals who provide person-centered care coordination and care management to participants in a FIDA plan. Each participant will have an interdisciplinary team (IDT). Each IDT will be comprised, first and foremost, of the participant and/or his or her designee, and the participant’s designated care manager, primary care physician, behavioral health professional, home care aide, and other providers either as requested by the participant or his or her designee or as recommended by the care manager or primary care physician and approved by the participant and/or his or her designee. The IDT facilitates timely and thorough coordination between a FIDA plan and the IDT, primary care physician and other providers. The IDT makes coverage determinations. Accordingly, the IDT’s decisions serve as service authorizations, may not be modified by a FIDA plan outside of the IDT, and are appealable by the participant, their providers and their representatives. IDT service planning, coverage determinations, care coordination and care management are delineated in the participant’s person-centered service plan and are based on the assessed needs and articulated preferences of the participant.

    Acronym for Medicare Advantage. An alternative to the traditional Medicare program in which private plans run by health insurance companies provide health care benefits that eligible beneficiaries would otherwise receive directly from the Medicare program.

    A type of health benefit plan that allows enrollees to go outside the health plan's provider network for care, but requires enrollees to pay higher out-of-pocket fees when they do. Also called Point of Service.

    A prepaid payment or series of payments made to a health plan by purchasers and often plan members for health insurance coverage.


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