N.Y. Comp. Codes R. & Regs. tit. 18 § 537.3

Current through Register Vol. 46, No. 45, November 2, 2024

Section 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

N.Y. Comp. Codes R. & Regs. Tit. 18 § 537.3