Statutes, codes, and regulations
California Code Of Regulations
Title 22 - Social SecurityDivision 3 - Health Care ServicesSubdivision 1 - California Medical Assistance ProgramChapter 3 - Health Care Services
Article 7 - Payment for Services and Supplies
Section 51518 - Optometry Services

Cal. Code Regs. tit. 22 § 51518

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Current through Register 2024 Notice Reg. No. 45, November 8, 2024
Section 51518 - Optometry Services
(a) General Provisions.
(1) The reimbursement for optometric services shall be in accordance with the maximum reimbursement rates listed below; however, billing shall not exceed charges made to the general public.
(2) Additional routine tests that may be needed shall be considered a part of the basic examination. Extensive treatment programs or difficult tests not included in the list below may be billed as unlisted items.
(3) Maximum allowances include preparation of necessary forms when an eye appliance is prescribed.
(4) Procedure Codes 92004, 92012 and 92014 are from the "Physicians' Current Procedural Terminology" Fourth Edition, 1990, (CPT-4), which is hereby incorporated by reference. Providers shall use all related guidelines and criteria listed in the 1990 CPT-4, as adopted by the Department, to bill for these CPT-4 procedure codes.
(b) Maximum reimbursement allowances for optometry services shall be as follows:
(1) Diagnostic and Ancillary Procedures.

Procedure Code

Maximum Rate

92002..........................Optometric service; medical examination and evaluation with initiation of diagnostic and treatment program, intermediate, new patient$32.80
92004..........................Optometric service; comprehensive, new patient, one or more visits. (To include case history, visual acuity testing, opthalmoscopy, ocular motility testing, testing for neurological integrity, refraction at far and near points, phorometric tests, confrontation fields and tonometry)47.45
92012..........................Optometric service, medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established patient (seen within six months of the comprehensive examination)22.59
92014..........................Optometric service; comprehensive, established patient, one or more visits. (To include case history, visual acuity testing, ophthalmoscopy, ocular motility testing, testing for neurological integrity, refraction at far and near points, phorometric tests, confrontation fields and tonometry)47.45
92020..........................Gonioscopy (separate procedure)16.40
92081..........................Visual field examination, unilateral or bilateral, with interpretation and report; limited examination (eg, tangent screen, Autoplot, arc perimeter, or single stimulus level automated test, such as Octopus 3 or 7 or equivalent)16.40
92082..........................Visual field examination, unilateral or bilateral, with interpretation and report; intermediate examination (eg, at least 2 isopters on Goldman perimeter, or semiquantitative, automated suprathreshold screening program, Humphrey suprathreshold automatic diagnostic test, Octopus program 33)22.14
92083..........................Visual field examination, unilateral or bilateral, with interpretation and report; extended examination, (eg, Goldmann visual fields with at least 3 isopters plotted and static determination within the central 30°, or quantitative, automated threshold perimetry, Octopus program G-1, 32 or 42, Humphrey visual field analyzer full threshold programs 30-2, 24-2, or 30/60-2)22.14
92100..........................Serial tonometry (separate procedure) with multiple measurements of intraocular pressure over an extended time period with interpretation and report, same day (eg, diurnal curve or medical treatment of acute elevation of intraocular pressure)28.93
92225..........................Ophthalmoscopy, extended, with retinal drawing (eg, for retinal detachment, melanoma), with interpretation and report, initial41.00
92250..........................Fundus photography with interpretation and report42.13
99201..........................Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a problem focused history; a problem focused examination; and straightforward medical decision making11.41
99202..........................Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: an expanded problem focused history; an expanded problem focused examination; and straightforward medical decision making34.30
99203..........................Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a detailed history; a detailed examination; and medical decision making of low complexity57.20
99204..........................Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a comprehensive history; a comprehensive examination; and medical decision making of moderate complexity68.90
99205..........................Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a comprehensive history; a comprehensive examination; and medical decision making of high complexity82.70
99211..........................Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician12.00
99212..........................Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a problem focused history; a problem focused examination; and straightforward medical decision making11.41
99213..........................Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity24.00
99214..........................Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a detailed history; a detailed examination; medical decision making of moderate complexity37.50
99215..........................Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a comprehensive history; a comprehensive examination; medical decision making of high complexity57.20
99241..........................Office consultation for a new or established patient, which requires these three key components: a problem focused history; a problem focused examination; and straightforward medical decision making30.60
99242..........................Office consultation for a new or established patient, which requires these three key components: an expanded problem focused history; an expanded problem focused examination; and straightforward medical decision making47.20
99243..........................Office consultation for a new or established patient, which requires these three key components: detailed history; a detailed examination; and medical decision making of low complexity59.50

(2) Supplemental Procedures

65205..........................Removal of foreign body, external eye; conjunctival superficial$ 6.74
65210..........................Removal of foreign body, external eye; conjunctival embeddeed (includes concretions), subconjunctival, or scleral nonperforating117.27
65220..........................Removal of foreign body, external eye; corneal, without slit lamp13.48
65222..........................Removal of foreign body, external eye; corneal, with slit lamp20.21
67820..........................Correction of trichiasis; epilation, by forceps only13.48
67938..........................Removal of embedded foreign body, eyelid273.27
68761..........................Closure of the lacrimal punctum; by plug, each125.47
68801..........................Dilation of lacrimal punctum, with or without irrigation136.63
Z2700..........................Low vision patient. To include professional evaluation, fitting and subsequent supervision, including six months' follow-up care75.11
Z2704..........................Detailed biomicroscopy/slit lamp evaluation9.88
Z2706..........................Contact lens examination (in addition to basic examination) to include multiple ophthalmometry, measurement of tear flow, measurement of ocular adnexa, initial tolerance evaluation, and other tests as necessary33.05
Z2708..........................Out-of-office call (add to procedure allowance)7.50
Z2710..........................Mileage--per mile one way beyond a ten-mile radius from point of origin1.36
Z2712..........................Diagnostic closure of the lacrimal punctum; by absorbable plug, 1 or more closures; includes office visits48.84
92499..........................Unlisted procedureBy Report

Cal. Code Regs. Tit. 22, § 51518

1. Amendment of subsection (b) filed 8-1-84 as an emergency; effective upon filing (Register 84, No. 31). A Certificate of Compliance must be transmitted to OAL within 120 days or emergency language will be repealed on 11-29-84. For prior history, see Register 81, No. 52.
2. Certificate of Compliance transmitted to OAL 11-27-84 and filed 12-27-84 (Register 84, No. 52).
3. Amendment of subsection (b) filed 8-1-85 as an emergency; effective upon filing (Register 85, No. 32). A Certificate of Compliance must be transmitted to OAL within 120 days or emergency language will be repealed upon 11-29-85.
4. Certificate of Compliance transmitted to OAL 11-20-85 and filed 12-27-85 (Register 85, No. 52).
5. Amendment of subsection (b)(2) filed 10-20-86; effective thirtieth day thereafter. Statutes of 1984, Chapter 258, Items 4260-106-001 and 890, and Statutes of 1985, Chapter III, Items 4260-106-001 and 890 (Register 86, No. 43).
6. Repealer and new section filed 9-25-92 as an emergency; operative 10-1-92 (Register 92, No. 40). A Certificate of Compliance must be transmitted to OAL 1-25-93 or emergency language will be repealed by operation of law on the following day.
7. Certificate of Compliance as to 9-25-92 order transmitted to OAL 1-22-93 and filed 3-9-93 (Register 93, No. 11).
8. Amendment of subsections (b)(1) and (b)(2) filed 7-21-98; operative 7-27-98 pursuant to Government Code section 11343.4(d) (Register 98, No. 30).
9. Amendment of subsection (a)(4) filed 7-21-98 as an emergency; operative 7-27-98 (Register 98, No. 30). A Certificate of Compliance must be transmitted to OAL by 11-24-98 or emergency language will be repealed by operation of law on the following day.
10. Editorial correction of HISTORY 9 (Register 99, No. 2).
11. Certificate of Compliance as to 7-21-98 order transmitted to OAL 11-23-98 and filed 1-7-99 (Register 99, No. 2).
12. Amendment of subsection (b)(1) and amendment of NOTE filed 11-13-2000 as an emergency; operative 11-13-2000 (Register 2000, No. 46). A Certificate of Compliance must be transmitted to OAL by 3-13-2001 or emergency language will be repealed by operation of law on the following day.
13. Certificate of Compliance as to 11-13-2000 order transmitted to OAL 3-13-2001 and filed 4-4-2001 (Register 2001, No. 14).
14. Amendment of subsections (b)(1)-(2) and amendment of NOTE filed 12-19-2001 as an emergency; operative 12-19-2001 (Register 2001, No. 51). A Certificate of Compliance must be transmitted to OAL by 4-18-2002 or emergency language will be repealed by operation of law on the following day.
15. Certificate of Compliance as to 12-19-2001 order transmitted to OAL 4-9-2002 and filed 4-30-2002 (Register 2002, No. 18).

Note: Authority cited: Sections 10725, 14105 and 14124.5, Welfare and Institutions Code. Reference: Section 14105, Welfare and Institutions Code; Statutes of 1999, Chapter 50, Items 4260-101-0001 and 0890; and Sections 11024, 11026, 11150 and 11210, Health and Safety Code.

1. Amendment of subsection (b) filed 8-1-84 as an emergency; effective upon filing (Register 84, No. 31). A Certificate of Compliance must be transmitted to OAL within 120 days or emergency language will be repealed on 11-29-84. For prior history, see Register 81, No. 52.
2. Certificate of Compliance transmitted to OAL 11-27-84 and filed 12-27-84 (Register 84, No. 52).
3. Amendment of subsection (b) filed 8-1-85 as an emergency; effective upon filing (Register 85, No. 32). A Certificate of Compliance must be transmitted to OAL within 120 days or emergency language will be repealed upon 11-29-85.
4. Certificate of Compliance transmitted to OAL 11-20-85 and filed 12-27-85 (Register 85, No. 52).
5. Amendment of subsection (b)(2) filed 10-20-86; effective thirtieth day thereafter. Statutes of 1984, Chapter 258, Items 4260-106-001 and 890, and Statutes of 1985, Chapter III, Items 4260-106-001 and 890 (Register 86, No. 43).
6. Repealer and new section filed 9-25-92 as an emergency; operative 10-1-92 (Register 92, No. 40). A Certificate of Compliance must be transmitted to OAL 1-25-93 or emergency language will be repealed by operation of law on the following day.
7. Certificate of Compliance as to 9-25-92 order transmitted to OAL 1-22-93 and filed 3-9-93 (Register 93, No. 11).
8. Amendment of subsections (b)(1) and (b)(2) filed 7-21-98; operative 7-27-98 pursuant to Government Code section 11343.4(d) (Register 98, No. 30).
9. Amendment of subsection (a)(4) filed 7-21-98 as an emergency; operative 7-27-98 (Register 98, No. 30). A Certificate of Compliance must be transmitted to OAL by 11-24-98 or emergency language will be repealed by operation of law on the following day.
10. Editorial correction of History 9 (Register 99, No. 2).
11. Certificate of Compliance as to 7-21-98 order transmitted to OAL 11-23-98 and filed 1-7-99 (Register 99, No. 2).
12. Amendment of subsection (b)(1) and amendment of Note filed 11-13-2000 as an emergency; operative 11-13-2000 (Register 2000, No. 46). A Certificate of Compliance must be transmitted to OAL by 3-13-2001 or emergency language will be repealed by operation of law on the following day.
13. Certificate of Compliance as to 11-13-2000 order transmitted to OAL 3-13-2001 and filed 4-4-2001 (Register 2001, No. 14).
14. Amendment of subsections (b)(1)-(2) and amendment of Note filed 12-19-2001 as an emergency; operative 12-19-2001 (Register 2001, No. 51). A Certificate of Compliance must be transmitted to OAL by 4-18-2002 or emergency language will be repealed by operation of law on the following day.
15. Certificate of Compliance as to 12-19-2001 order transmitted to OAL 4-9-2002 and filed 4-30-2002 (Register 2002, No. 18).