S0621 — Routine ophthalmological examination including refraction; established patient
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Record visual acuity with current correction (power documented) at distance and, when appropriate, at near; include refraction when indicated.
- Document visual fields by confrontation or automated screening devices (non-threshold).
- Document external examination findings: eyelid position and character, lashes, lacrimal apparatus and tear function, globe position, and pertinent facial features.
- Document pupillary function: size, light response, and assessment for relative afferent pupillary defect.
Key Coverage Criteria
- Routine preventive ophthalmic evaluation to detect common and serious ocular abnormalities.
- Periodic re-examination of all patients, with emphasis on those who have risk factors for ocular disease, to prevent or minimize vision loss through early detection and treatment.
- Preventive (routine) eye examinations to evaluate the visual system and related ocular structures.
- Periodic re‑examination after an initial comprehensive exam that is normal or only shows refractive (optical) abnormalities to detect new or asymptomatic ocular disease (examples: glaucoma, diabetic retinopathy, age‑related macular degeneration).
- Comprehensive evaluations for patients with no risk factors at routine intervals (frequencies specified elsewhere in the policy).
- Pediatrics: follow CPG.VP.47 Pediatric Eye Examinations.
1 Active Policy
AMBETTER-CP.VP.13 — Preventative (Routine) Eye Examination
Related Codes
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