18 CRR-NY 537.3NY-CRR
18 CRR-NY 537.3
18 CRR-NY 537.3
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 self-employed optometrist only | 8.00 |
| 60006 | Orthoptic evaluation; reimbursable to self-employed optometrist only | 8.00 |
| 60007 | Orthoptic training (per session); reimbursable to self-employed 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 7.00 D | 6.00 |
| 60214 | 7.25 D to 18.00 D | 7.75 |
| 60216 | 18.25 D or higher | By Report |
| COMPOUNDS: (+ on − or − on −) | ||
| 60223 | Plano to 7.00 DS; 0.25 DC to 4.00 DC | 6.80 |
| 60224 | 7.25 DS to 18.00 DS; 0.25 DC to 4.00 DC | 8.55 |
| 60226 | 18.25 DS or higher; 0.25 DC to 4.00 DC | 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 7.00 D | 8.05 |
| 60514 | 7.25 D to 18.00 D | 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 6.00 D | 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 | |
18 CRR-NY 537.3
Current through July 31, 2021
| End of Document |