Coding Requirements for Comprehensive Ophthalmological Services Updates

Date: 08/24/26

Effective October 1, 2026, Meridian Medicaid Plan will require that claims billed for routine or preventive comprehensive ophthalmological services (CPT® 92004 and 92014) include a medical (non-refractive) diagnosis or comorbidity in addition to any refractive or routine diagnosis. The medical diagnosis must be listed after the refractive or routine diagnosis. Claims submitted for comprehensive ophthalmological services without a secondary medical diagnosis will be denied.

Services performed for members with only refractive or routine findings should be billed as intermediate ophthalmological services (CPT® 92002 and 92012). This requirement aligns with guidance in the American Medical Association CPT® Manual, which states that comprehensive ophthalmological services include the initiation of diagnostic and treatment programs. Intermediate and comprehensive ophthalmological services are integrated services in which medical decision-making is part of the reported service.

Examples

Comprehensive Ophthalmological Service (CPT® 92004/92014)

A member presents for an eye examination and is diagnosed with a refractive error and a coexisting medical condition, such as ocular allergies. The provider initiates a treatment plan for the medical condition.

In this scenario, report CPT® 92004 or 92014 and include the refractive diagnosis followed by the medical diagnosis that supports the initiation of a diagnostic or treatment program.

Intermediate Ophthalmological Service (CPT® 92002/92012)

A member presents for an eye examination and is found to have a refractive error only, with no additional medical conditions. In this scenario, report CPT® 92002 or 92012 with the appropriate diagnosis.

For questions, call Meridian Provider Services at 866-606-3700, Monday through Friday, from 8 a.m. to 5 p.m. You may also contact your Provider Engagement representative at ILProviderRelations@mhplan.com for assistance.