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Medical Plan vs. Vision Plan

The monitoring of eye and eyelid related conditions that cause you discomfort or potentially cause damage to your eye(s) or vision are health conditions that are covered by the same insurance plan that you would use for discomfort or potential damage to any other part of your body. That is, your “major medical insurance” plan is responsible for any visit to our office when the “reason” or purpose is to evaluate a known “condition” or “symptom” and manage it appropriately.

In some cases these conditions are temporary and, once resolved no longer need management (a cut, an abrasion a “broken blood vessel”). Most of the time they are ongoing or “chronic” and require persistent evaluation and management (dry eye, eyelid conditions, cataracts, glaucoma “suspects”, etc).

Therefore, if you have one of these conditions, it is the appropriate and responsible approach for us to use your “medical” insurance for the care provided when an office visit has that “focus” or “reason.” Because some visits have “multiple reason(s)” it may be appropriate to use either (but not both) your “medical” or a “vision” benefit plan.

When it is deemed appropriate to use medical insurance for a “comprehensive eye and vision examination” (coded in the CPT standards as 92004 or 92014) it will almost always also include an evaluation of the “refractive power” of your eyes (along with muscle-focussing evaluation and binocular vision evaluation when necessary) – this is coded in CPT as a 92015. We also desire every patient have a yearly retina scan (Optomap retinal imaging).


*= patient responsibility will VARY depending on “co-payments” / “deductibles” and what other medical services have been utilized so far in the calendar year.

When a “vision benefit plan” is used, the examination and refraction code are usually considered “together” and a single co-payment is applied to both services – Optomap imaging is still considered separately.


*= patient responsibility will VARY depending on “co-payments” / “deductibles” and what other vision services have been utilized so far in the benefit year.