Montana Medicaid – Fee Schedule Eyeglasses December 1, 2016 Please see first page for a complete description of information contained in the fee schedules. 1 Fees as of December 2016 Definitions: Modifier – When a modifier is present, this indicates system may have different reimbursement or code edits for that procedure code/modifier combination. For example: 26 = professional component TC = technical component Description – Procedure code description. You must refer to the appropriate official CPT-4 or HCPCS coding manual for complete definitions in order to assure correct coding. Effective – This is the first date of service for which the listed fee is applicable. Method – Source of fee determination Fee Sched: Medicaid fee for listed code Medicare: Medicare-prevailing fee for listed code. PA – Prior Authorization Y: Prior authorization is required Space: Prior authorization is not required CPT codes, descriptors, and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Apply. Montana Medicaid – Fee Schedule Eyeglasses December 1, 2016 Please see first page for a complete description of information contained in the fee schedules. 2 Fees as of December 2016 Proc Modifier Description Effective Method Fee PA V2020 VISION SVCS FRAMES PURCHASES 12/1/2016 FEE SCHED $10.00 V2025 EYEGLASSES DELUX FRAMES 12/1/2016 FEE SCHED $30.00 Y V2100 LENS SPHER SINGLE PLANO 4.00 12/1/2016 FEE SCHED $1.00 V2101 SINGLE VISN SPHERE 4.12-7.00 12/1/2016 FEE SCHED $1.00 V2102 SINGL VISN SPHERE 7.12-20.00 12/1/2016 FEE SCHED $5.75 V2103 SPHEROCYLINDR 4.00D/12-2.00D 12/1/2016 FEE SCHED $11.00 V2104 SPHEROCYLINDR 4.00D/2.12-4D 12/1/2016 FEE SCHED $11.00 V2105 SPHEROCYLINDER 4.00D/4.25-6D 12/1/2016 FEE SCHED $5.75 V2106 SPHEROCYLINDER 4.00D/>6.00D 12/1/2016 FEE SCHED $5.75 V2107 SPHEROCYLINDER 4.25D/12-2D 12/1/2016 FEE SCHED $5.75 V2108 SPHEROCYLINDER 4.25D/2.12-4D 12/1/2016 FEE SCHED $5.75 V2109 SPHEROCYLINDER 4.25D/4.25-6D 12/1/2016 FEE SCHED $5.75 V2110 SPHEROCYLINDER 4.25D/OVER 6D 12/1/2016 FEE SCHED $5.75 V2111 SPHEROCYLINDR 7.25D/.25-2.25 12/1/2016 FEE SCHED $5.75 V2112 SPHEROCYLINDR 7.25D/2.25-4D 12/1/2016 FEE SCHED $5.75 V2113 SPHEROCYLINDR 7.25D/4.25-6D 12/1/2016 FEE SCHED $5.75 V2114 SPHEROCYLINDER OVER 12.00D 12/1/2016 FEE SCHED $5.75 V2121 LENTICULAR LENS SINGLE 12/1/2016 FEE SCHED $20.00 V2200 LENS SPHER BIFOC PLANO 4.00D 12/1/2016 FEE SCHED $1.00 V2201 LENS SPHERE BIFOCAL 4.12-7.0 12/1/2016 FEE SCHED $1.00 V2202 LENS SPHERE BIFOCAL 7.12-20. 12/1/2016 FEE SCHED $1.00 V2203 LENS SPHCYL BIFOCAL 4.00D/.1 12/1/2016 FEE SCHED $11.70 V2204 LENS SPHCY BIFOCAL 4.00D/2.1 12/1/2016 FEE SCHED $11.70 V2205 LENS SPHCY BIFOCAL 4.00D/4.2 12/1/2016 FEE SCHED $8.50 V2206 LENS SPHCY BIFOCAL 4.00D/OVE 12/1/2016 FEE SCHED $8.50 V2207 LENS SPHCY BIFOCAL 4.25-7D/. 12/1/2016 FEE SCHED $8.50 V2208 LENS SPHCY BIFOCAL 4.25-7/2. 12/1/2016 FEE SCHED $8.50 V2209 LENS SPHCY BIFOCAL 4.25-7/4. 12/1/2016 FEE SCHED $1.00 V2210 LENS SPHCY BIFOCAL 4.25-7/OV 12/1/2016 FEE SCHED $1.00 V2211 LENS SPHCY BIFO 7.25-12/.25- 12/1/2016 FEE SCHED $1.00 V2212 LENS SPHCYL BIFO 7.25-12/2.2 12/1/2016 FEE SCHED $1.00 V2213 LENS SPHCYL BIFO 7.25-12/4.2 12/1/2016 FEE SCHED $1.00 V2214 LENS SPHCYL BIFOCAL OVER 12. 12/1/2016 FEE SCHED $1.00 V2220 LENS BIFOCAL ADD OVER 3.25D 12/1/2016 FEE SCHED $5.00 Y V2221 LENTICULAR LENS BIFOCAL 12/1/2016 FEE SCHED $25.00 V2300 LENS SPHERE TRIFOCAL 4.00D 12/1/2016 FEE SCHED $1.00 V2301 LENS SPHERE TRIFOCAL 4.12-7. 12/1/2016 FEE SCHED $1.00 V2302 LENS SPHERE TRIFOCAL 7.12-20 12/1/2016 FEE SCHED $9.50 V2303 LENS SPHCY TRIFOCAL 4.0/.12- 12/1/2016 FEE SCHED $8.00 V2304 LENS SPHCY TRIFOCAL 4.0/2.25 12/1/2016 FEE SCHED $8.00 V2305 LENS SPHCY TRIFOCAL 4.0/4.25 12/1/2016 FEE SCHED $1.00 V2306 LENS SPHCYL TRIFOCAL 4.00/>6 12/1/2016 FEE SCHED $1.00 V2307 LENS SPHCY TRIFOCAL 4.25-7/. 12/1/2016 FEE SCHED $1.00 Montana Medicaid – Fee Schedule Eyeglasses December 1, 2016 Please see first page for a complete description of information contained in the fee schedules. 3 Fees as of December 2016 Proc Modifier Description Effective Method Fee PA V2308 LENS SPHC TRIFOCAL 4.25-7/2. 12/1/2016 FEE SCHED $1.00 V2309 LENS SPHC TRIFOCAL 4.25-7/4. 12/1/2016 FEE SCHED $1.00 V2310 LENS SPHC TRIFOCAL 4.25-7/>6 12/1/2016 FEE SCHED $1.00 V2311 LENS SPHC TRIFO 7.25-12/.25- 12/1/2016 FEE SCHED $1.00 V2312 LENS SPHC TRIFO 7.25-12/2.25 12/1/2016 FEE SCHED $1.00 V2313 LENS SPHC TRIFO 7.25-12/4.25 12/1/2016 FEE SCHED $1.00 V2314 LENS SPHCYL TRIFOCAL OVER 12 12/1/2016 FEE SCHED $1.00 V2321 LENTICULAR LENS TRIFOCAL 12/1/2016 FEE SCHED $40.00 V2710 GLASS/PLASTIC SLAB OFF PRISM 12/1/2016 FEE SCHED $25.00 V2715 PRISM LENS/ES 12/1/2016 FEE SCHED $5.00 V2718 FRESNELL PRISM PRESS-ON LENS 12/1/2016 FEE SCHED $20.00 V2744 TINT PHOTOCHROMATIC LENS/ES 12/1/2016 FEE SCHED $18.00 Y V2744 UC TINT PHOTOCHROMATIC LENS/ES 12/1/2016 FEE SCHED $18.00 Y V2745 TINT ANY COLOR/SOLID/GRAD 12/1/2016 FEE SCHED $2.00 Y V2755 UV LENS/ES 12/1/2016 FEE SCHED $1.00 Y V2760 SCRATCH RESISTANT COATING 12/1/2016 FEE SCHED $1.00 Y V2781 PROGRESSIVE LENS PER LENS 12/1/2016 FEE SCHED $27.00 V2784 LENS POLYCARB OR EQUAL 12/1/2016 FEE SCHED $4.00 Y