Eye Examination Benefits

Routine eye examinations are not a MSP benefit for individuals aged 19 to 64 years. Medically required eye examinations continue to be a benefit for all MSP beneficiaries. We are providing the following information to clarify the changes to the eye examination benefits and to provide more detail on when a referral is required.

Eye Examination Benefits

An eye examination is an insured benefit if medically required. The diagnoses which meet the MSP definition of medically required are listed below by ICD9 code, and are payable at the frequency indicated. To support exceptions to these frequencies or for other special circumstances, please ensure this information is included with your referral.

In general, the criteria for medically required include:

• ocular disease, trauma or injury
• systemic diseases associated with significant ocular risk (e.g. diabetes)
• medications associated with significant ocular risk

Formal referrals to ophthalmologists or direct requests to optometrists for an eye examination on behalf of patients are appropriate only if, in the practitioner’s judgement and based on clinical evidence, there is medical necessity for the examination.

Refractive change (needing glasses or contact lenses) with no other pathology does not meet the MSP medically required criteria for payment. Patients presenting with refractive change only should not be formally referred for an eye exam by you or your office. These patients should contact their ophthalmologist or optometrist directly to request an eye exam and they should also be advised that payment of the eye examination would be their responsibility.

MSP will be monitoring billings and conducting audits of referrals to assess compliance with the criteria defining medically required services.

Information for Ophthalmologists

MSP will accept claims and make payment for services provided by ophthalmologists upon referral from general practitioners. Patients who have been referred by a GP must not be charged for an eye exam.

It is the responsibility of General Practitioners to exercise their judgement in referring those patients for whom an eye examination is medically required. This does not include visits for patients with refractive change (needing glasses or contact lenses) but with no other pathology. MSP will monitor referral patterns to ensure adherence to this policy.

MSP coverage of eye examinations for patients on income-assistance is the same as for other MSP beneficiaries. Medically required examinations are covered; however, visits for refractive changes (for glasses or contact lenses) are not a benefit for individuals aged 19 to 64. For patients insured under the First Nations Health Authority (FNHA), prior approval is required for health benefits.

For more information on Benefits, please go to the FNHA web site, or contact them as follows:

BC Region (toll free):1 800 317-7878
Vancouver:1 888 321-5003

Have your Status Card and CareCard ready.

Medically Required Eye Examinations – Fee item 02015

An eye examination is an insured benefit if medically required. The diagnoses which meet the MSP definition of medically required are listed below by ICD9 code, and are payable at the frequency indicated. To support exceptions to these frequencies or for other special circumstances please ensure this information is included with your referral.

In general, medically required examinations include the following:

• ocular disease, trauma or injury
• systemic diseases associated with significant ocular risk (e.g. diabetes)
• medications associated with significant ocular risk

It is appropriate to bill 02015 in the following situations:

For eye exams which meet the medically required criteria, but are not initiated by a GP referral.

Consultation referred by GP for significant pathology – Fee item 02010

For eye exams which meet the medically required criteria, but are not initiated by a GP referral.

A consultative fee will be paid to the consultant where a patient is referred on a no charge basis for an eye examination and the consultant in his/her examination finds significant eye pathology, so indicates and completes a written report to the referring medical practitioner.

Repeat or Limited Consultation referred by GP but no pathology found – Fee item 02011

A repeat or limited consultation should apply when a consultation is repeated for the same condition within six months of the last visit or when in the judgement of the consultant the service does not warrant a full consultative fee. Therefore, if you receive a referral from a general practitioner and in your judgement a full consultation is not necessary a repeat or limited consultation should be billed.

For billing information please call Health Insurance British Columbia (HIBC):

Victoria: 1 866 456-6950
Vancouver: 604 456-6950

Press 2 and Press 2

The following diagnoses are considered medically required, and eye examinations are payable at the frequency indicated. A note record documenting the medical necessity must be included to support exceptions to these frequencies.

Services for conditions not listed below are the responsibility of the patient unless a referral is medically indicated and provided to the ophthalmologist directly by the referring physician.

Please note, under each three digit diagnostic code – the four and five digit codes in the same category would be limited to the same frequency guidelines. The exceptions are listed below (3620, 36201 and 36202).

Eye examinations billed with the following diagnostic codes are payable once every 24 months:

360	Disorders of the globe
363	Chorioretinal inflammations, scars and other disorders of choroid
368	Visual disturbances
369	Blindness and low vision
375	Disorders of lacrimal system
379	Other disorders of eye
4019	Hypertensive disease not specified as malignant or benign
05440	Herpes simplex – ophthalmic (acute onset)
05320	Herpes zoster – ophthalmic (acute onset)
94010	Burns of eyelids and periocular area
92190	Unspecified contusion of eye
9182	Superficial injury – conjunctiva
9301	Foreign body in conjunctival sac
9181	Superficial injury – cornea
9300	Corneal foreign body
8026	Fracture – orbital floor (blow out), closed
9502	Injury to optic pathways
9503	Injury to visual cortex
99520	Unspecified adverse effect of drug, medicament and biological (allergic reaction to medication)

Eye examinations billed with the following diagnostic codes are payable once every 12 months:

361	Retinal detachments and defects
362	Other retinal disorders
364	Disorders of iris and ciliary body
365	Glaucoma
366	Cataract
370	Keratitis
371	Corneal opacity and other disorders of cornea
372	Disorders of conjunctiva
373	Inflammation of eyelids
374	Other disorders of eyelids
376	Disorders of the orbit
377	Disorders of optic nerve and visual pathways
378	Strabismus and other disorders of binocular eye movements
27910	Deficiency of cell mediated immunity (AIDS (HIV))
7200	Ankylosing Spondylitis
43600	Cerebrovascular disease – acute but ill defined
17400	Malignant neoplasm of breast
16200	Malignant neoplasm of trachea, bronchus and lung
34000	Multiple sclerosis
35800	Myasthenia Gravis
23700	Neoplasm – pituitary gland and craniopharyngeal duct
13500	Sarcoidosis
24000	Goitre, specified as simple
71020	Sicca Syndrome (Sjogren’s Syndrome)
71000	Systemic Lupus Erythematosus
44650	Giant Cell Arteritis (Temporal Arteritis)
224	Benign neoplasm of eye
8717	Unspecified ocular penetration
E07	Intraocular surgery or injury with penetrating wound
9404	Burn – Cornea / Conjunctiva
V6751	Following high risk medications ***

*** Claims with this code must be accompanied by a note stating type of medication.

Eye examinations billed with the following diagnostic codes are payable once every 6 months:

250	Diabetes Mellitus
3620	Diabetic Retinopathy
36201	Background diabetic retinopathy
3620	Proliferative diabetic retinopathy