Ocular Benefits KanCare Provider Manual. Effective January 1, 2013

Ocular nefits KanCare Provider Manual Effective January 1, 2013

Provider Manual Introduction... 3 Ocular nefits Provider Experience... 4 Our Commitment to Service... 4 Access to Flexible Participation Options... 4 Outreach Programs... 4 Technology Tools... 5 Feedback... 6 Quick Reference Information... 7 Provider Web Portal Registration & Introduction... 10 Registration... 10 Introduction... 12 ELECTRONIC FUNDS TRANSFER (EFT) AUTHORIZATION AGREEMENT... 17 Statement of Member Rights and Responsibilities... 18 Statement of Provider Rights and Responsibilities... 19 Member Eligibility Verification Procedures and Services to Members... 20 Member Identification Card... 20 Ocular nefits Eligibility Systems... 20 Transportation nefits for Certain Members... 21 Appointment Availability Standards... 21 Ocular nefits Provider Manual... 21 Covered nefits... 22 Missed Appointments... 22 Payment for Non-Covered Services... 23 Claim Submission Procedures... 25 Electronic Claim Submission Utilizing Ocular nefits Website... 25 Electronic Claim Submission via Clearinghouse... 25 HIPAA Compliant 837P File... 25 Paper Claim Submission... 25 Claims Adjudication and Payment... 26 Coordination of nefits (COB)... 26 Filing Limits... 26 Receipt and Audit of Claims... 27 Ocular nefits CONFIDENTIAL Provider Manual 1

Important Notice for Submitting Paper Authorizations and Claims... 29 UB-04 Claim Form... 30 CMS-1500 Claim Form... 31 Inquiries, Grievances and Appeals... 32 Inquiry... 32 Grievances... 32 Health Insurance Portability and Accountability Act (HIPAA)... 34 Credentialing... 35 Member Access... 36 Appointment Availability Standards... 36 Emergency Services... 36 Out of Network... 36 Utilization Management Treatment Decisions... 37 Introduction... 37 Community Practice Patterns... 37 Evaluation... 37 Results... 37 Fraud and Abuse... 38 Deficit Reduction Act of 2005: The False Claims Act... 38 Random Chart Audits... 39 Time Frame... 39 Medical Necessity... 40 Utilization Review... 41 Clinical Guidelines... 41 Peer to Peer Requests... 41 Prior Authorization, Retrospective Review, and Documentation Requirements... 42 Procedures Requiring Prior Authorization... 42 Retrospective Review... 42 Attachment 1 Office Visit Authorization Request Form... Error! Bookmark not defined.2 Attachment 2 Medical/Surgical Review Form... Error! Bookmark not defined.3 Ocular nefits CONFIDENTIAL Provider Manual 2

Introduction Welcome to the Ocular nefits Provider Network! We are pleased you have joined our Provider network, which is composed of the best Providers in the state. Ocular nefits is a national leader in the administration of federally funded contracts such as Medicare and Medicaid. Ocular nefits leverages over 17 years of experience in delivering medical surgical ophthalmic services. Ocular nefits accepts full health plan delegation for claims management, provider credentialing, network management and utilization management. Ocular nefits provides comprehensive medical-surgical eye care from medical exams to complex ocular surgical procedures. Ocular nefits offers an integrated medical network that includes optometric primary eye care doctors, ophthalmologists, subspecialists and eye surgeons. In addition, we provide ambulatory surgical centers, anesthesia and inoffice pharmacy. Ocular nefits retains the right to add to, delete from and otherwise modify this Provider manual with 30 days prior notice. Contracted Providers must acknowledge this Provider manual and any other written materials provided by Ocular nefits as proprietary and confidential. Dr. Michael Hecht, O.D., Assistant Medical Director Dr. Hecht serves as our Assistant Medical Director and assists the Medical Director with all of Ocular nefits clinical, utilization review and utilization management activities. He also gives guidance to our clinical review department to ensure accuracy and consistency in the review process. Ocular nefits CONFIDENTIAL Provider Manual 3

Ocular nefits Provider Experience Committed optometrists and ophthalmologists are critical to the success of every government-sponsored ocular program. At Ocular nefits, we ve structured our Provider networks to give optometrists and ophthalmologists the flexibility they need to participate in ocular programs on their own terms. Ocular nefits considers itself an ally of optometry and ophthalmology associations while maintaining flexibility within the changing political climate surrounding government-sponsored ocular programs. We recognize the significant link between good ocular care and overall patient health and advocate increasing Provider funding while improving Member education and outreach. Ocular nefits partners with ocular Providers to deliver high-quality care and services to all Members of government-sponsored ocular programs. Our Commitment to Service Ocular nefits has established the following core concepts in its approach to a positive Provider experience: Access: Access to flexible participation options in Provider networks. Outreach: Outreach programs to lower Provider participation costs. Technology: Technology tools to increase efficiency and lower administrative costs. Feedback: Feedback to measure Provider and Member satisfaction. Access to Flexible Participation Options Ocular nefits invites all licensed optometrists and ophthalmologists, regardless of their past commitment to government-sponsored ocular programs, to participate in its Provider network. Providers can choose their own level of participation for each of their practice locations. For example, Providers can choose to: Limit panel size- if your office is at capacity, you can limit your practice to treat existing patients only. Treat only emergencies or special needs cases on an individual basis. Provide only primary medical eye care. Access web-based applications and credentialing. To make it easy to apply and be accepted into the program, Ocular nefits uses website links and electronic documents to streamline the Provider/clinic contracting and credentialing process. Once Providers participate in the Ocular nefits network at any level, web-based technology tools and innovative programs are employed to drive down Provider participation costs. Outreach Programs Lowering costs and ensuring a positive experience are the focus points for Ocular nefits Provider outreach programs. Provider Bill of Rights To be treated with respect. To be paid accurately. To be paid on time. Ocular nefits CONFIDENTIAL Provider Manual 4

Consistent, transparent authorization determination logic Ocular nefits has trained paraprofessionals and ocular consultants that use clinical criteria to ensure a consistent approach for determining authorizations. Ocular nefits clinical criteria is available at the Provider services website so optometrists and ophthalmologists can follow the decision matrix and understand the logic behind authorization decisions. In addition, Ocular nefits fosters a sense of partnership by encouraging Providers to offer feedback regarding clinical criteria. A consistent, well-understood approach to authorization determinations promotes clarity and transparency for Providers, which in turn reduces Provider administrative costs. Technology Tools Ocular nefits takes advantage of technology to increase speed and efficiency while keeping program administration and Provider participation costs as low as possible. Paperless insurance company The paperless insurance company concept is a central component of Ocular nefits attempt to eliminate paper transactions. Replacing paper with electronic transactions lowers costs for Providers and rewards them with preferential status whenever possible. Providers can: Submit claims and authorizations electronically, in any format convenient for the Provider office Receive remittances and payments Verify Member eligibility Check claim and authorization status View the results of Member satisfaction surveys Receive ongoing communication Note that paper claims will still be accepted through the KMAP Fiscal nt. See the section on Paper Claims Submission for more information. Provider Web Portal Ocular nefits Provider Web Portal allows participating Providers direct access to the Enterprise System benefits administration software. Taking advantage of the online services offered through the Provider Web Portal lowers program administration and participation costs. Online access requires only an internet browser, a valid user ID, and a password. From an internet browser, Providers and authorized office staff can log in for secured access to the system anytime from anywhere to handle a variety of day-to-day tasks, including: Verifying Member eligibility. Checking patient treatment history for specific services. Submitting claims for services rendered by simply entering procedure codes, etc. Submitting authorization requests, using interactive clinical algorithms when appropriate. Sending electronic attachments, such as medical records, EOBs, and treatment plans. Checking the status of submitted claims and authorizations. Accessing and reviewing remittance information. Downloading and printing Provider Manuals, Clinical Criteria and Fee Schedules. Ocular nefits CONFIDENTIAL Provider Manual 5

Setting up office appointment schedules, which can automatically verify eligibility and pre-populate claim forms for online submission. Reviewing Provider clinical profiling data relative to peers. Uploading and downloading documents using a secure encryption protocol. Participating in Provider surveys to rate satisfaction with Ocular nefits. Feedback At Ocular nefits, feedback from Members and Providers is encouraged, logged, and acted upon when appropriate. Ocular nefits conducts web and telephone satisfaction surveys to gather valuable feedback for its Quality Improvement initiatives. Additionally, Ocular nefits invites feedback from Providers regarding authorization determination algorithms to help foster a sense of teamwork and cooperation. Ocular nefits CONFIDENTIAL Provider Manual 6

Quick Reference Information Ocular nefits provides access to a Web Portal containing the full complement of online Provider resources. The Web Portal features an online Provider inquiry tool for real-time eligibility, claims, and authorization status. Visit the Web Portal at www.ocularbenefits.com for helpful resources including: Standard forms Ocular nefits Provider Manual Referral directories Provider newsletter Claims status Electronic remittance advice Electronic funds transfer information QUICK REFERENCE INFORMATION Member Eligibility Participating Providers may access eligibility information through: Logging in to Provider Web Portal via www.ocularbenefits.com Contacting Ocular nefits Provider Services at 1-866-416-0150 National Provider Identifier (NPI) The Health Insurance Portability and Accountability Act (HIPAA) of 1996 require the adoption of a standard unique Provider identifier for health care Providers. participating Providers must have an NPI number. An NPI is a 10-digit, intelligence-free numeric identifier. Intelligence-free means that the numbers do not carry information concerning health care Providers, for instance the states in which they practice or their specialties. Providers can apply for an NPI by: Completing the application online at https://nppes.cms.hhs.gov Completing a paper copy by downloading it at https://nppes.cms.hhs.gov Calling 1-800-465-3203 and requesting an application Estimated time to complete the NPI application is 20 minutes Ocular nefits CONFIDENTIAL Provider Manual 7

Authorization Information Prior authorization determinations must be made within 14 days from the date Ocular nefits receives this request for all non-urgent requests, provided all information is complete. Prior authorizations will be honored for 30 days from the date they are determined. Authorization submissions can be received in the following formats: Electronic authorizations via Ocular nefits website at www.ocularbenefits.com Phone at 1-866-416-0150 Fax at 1.800.310.9871 Mailed authorizations should be sent to the following address: Ocular nefits Authorizations PO Box 1616 Milwaukee, WI 53201 Claims Information The timely filing requirement for Ocular nefits is 180 calendar days. Claims submissions can be received in the following formats: Electronic claims via Ocular nefits website at Ocular nefits.com Electronic submission via clearinghouse HIPAA Compliant 837P file Ocular nefits will only accept paper claims through KDHE. Submit claims to: Kansas Medical Assistance Program Office of the Fiscal nt P.O. Box 3571 Topeka, KS 66601-3571 Ocular nefits CONFIDENTIAL Provider Manual 8

Inquiries and Grievance To make an inquiry or complaint, contact Ocular nefits Provider Services toll-free at 1-866-416-0150 To file a written grievance, send to the following address: Ocular nefits Grievances PO Box 1616 Milwaukee, WI 53201 Provider Appeals Information Payment Appeals must be filed within 30 days following the date the denial letter was mailed. Submit appeal to: Ocular nefits Appeals PO Box 1616 Milwaukee, WI 53201 Providers must exhaust all appeal rights prior to requesting a Fair Hearing. Fair Hearing requests, must be submitted in writing to the following address: Office Of Administrative Hearings 1020 S. Kansas Ave. Topeka, KS 66612-1327 Member Appeals Information A member has 30 days from the date of the notification to file an appeal. An appeal can be made either in writing or by a verbal noticifcation. For verbal requests, please contact Amerigroup s Member Services Department at 1-800-600-4441.. Written appeals must be submitted to the following address: Central Appeals Processing Amerigroup Kansas P.O. Box 62429 Virginia ach, VA 23466-2429 Ocular nefits CONFIDENTIAL Provider Manual 9

Provider Web Portal Registration & Introduction The Ocular nefits Provider Web Portal services allow us to maintain our commitment to help Providers keep office costs low, access information efficiently, receive payments quicker, and submit claims and authorizations electronically. Registration To register for our Provider Web Portal visit www.ocular nefits.com, click on the Providers login tab, and follow the Register Now link. Ocular nefits CONFIDENTIAL Provider Manual 10

There is no need to download or purchase software. To access the Provider Web Portal, enter a unique user name and password. Select As a payee for the option to view remittances. Contact Provider Services at 1-866-416-0150 to obtain your Payee ID number. Ocular nefits CONFIDENTIAL Provider Manual 11

Introduction Once registered, you are now ready to navigate through the web portal and use the available resources and features to help streamline data entry. Verify Member Eligibility One-step Member eligibility verification Verify up to 250 Members at one time Ocular nefits CONFIDENTIAL Provider Manual 12

Manage claims Submit claims for services performed. Review and print or save a list of claims submitted today for your records, before they are sent on for processing. Check the status of previously submitted claims. Enter additional information regarding the claim in the Notes tab Ocular nefits CONFIDENTIAL Provider Manual 13

Manage Authorizations Submit authorizations before performing services to obtain approval. Attach electronic files, including medical records and review authorizations submitted today, before they are sent on for processing. Check the status of previously submitted authorizations. Ocular nefits CONFIDENTIAL Provider Manual 14

From an Authorization Summary, you can: Run any applicable authorization guidelines. Review a list of documentation required for each procedure code. Attach electronic files to the authorization record. Attach clearing house reference information to the authorization record. Print a copy of the Authorization Summary for your records. Ocular nefits CONFIDENTIAL Provider Manual 15

Electronic Funds Transfer The Ocular nefits Provider Web Portal services allow us to give you quicker payments by electronic funds transfers (EFT s). The electronic payment offers a direct deposit into your account and allows you to obtain remits quicker on your online account. To obtain your online remittances, navigate to the My Documents page from the documents tab on the toolbar or by the link on the main page. To enroll in EFT payment, please complete the following page and return to Ocular nefits via: Fax: 262.721.0722; Email: providers@ocularbenefits.com; Mail: N92W14612 Anthony Ave, Menomonee Falls, WI 53051 Ocular nefits CONFIDENTIAL Provider Manual 16

ELECTRONIC FUNDS TRANSFER (EFT) AUTHORIZATION AGREEMENT PART I REASON FOR SUBMISSION Reason for Submission: New EFT Authorization Revision to Current EFT setup (e.g. account or bank changes) PART II PROVIDER OR SUPPLIER INFORMATION Name of Payee: Tax Identification Number: (Designate SSN or EIN ) Address of Payee (City, State, Zip): PART III DEPOSITORY INFORMATION (Financial Institution) Bank/Depository Name Depository Routing Transit Number (nine digits include any leading zeros) Depositor Account Number (up to 10 digits include any leading zeros) of Account (check one) Checking Account Savings Account PART IV CONTACT INFORMATION Name of Billing Contact: Phone Number of Billing Contact: Email Address of Billing Contact: PART V AUTHORIZATION I hereby authorize Ocular nefits to initiate credit entries, and in accordance with 31 CFR part 210.6(f) initiate adjustments for any credit entries made in error to the account indicated above. I hereby authorize the financial institution/bank named above, hereinafter called the DEPOSITORY, to credit the same to such account. This authorization agreement is effective as of the signature date below and is to remain in full force and effect until the CONTRACTOR has received written notification from me of its termination in such time and such manner as to afford the CONTRACTOR and the DEPOSITORY a reasonable opportunity to act on it. The CONTACTOR will continue to send the direct deposit to the DEPOSITORY indicated above until notified by me that I wish to change the DEPOSITORY receiving the direct deposit. If my DEPOSITORY information changes, I agree to submit to the CONTRACTOR an updated EFT Authorization Agreement. Signature of Authorized Billing Contact: Date: Ocular nefits CONFIDENTIAL Provider Manual 17

Statement of Member Rights and Responsibilities Ocular nefits is committed to the following core concepts in its approach to Member care: Access: Access to Providers and services. Wellness: Wellness programs, which include Member education and disease management initiatives. Outreach: Outreach programs that educate Members and give them the tools they need to make informed decisions about their ocular care. Feedback: Feedback from Members through ongoing Member satisfaction surveys and Provider evaluations with Rate a Provider rankings. yond these four core concepts, Ocular nefits also believes in the following set of values. Members have the right to: Privacy and to be treated with respect and recognition of their dignity when receiving ocular care, which is a private and personal service. Fully participate with caregivers in the decision making process surrounding their health care. fully informed about the appropriate or medically necessary treatment options for any condition, regardless of the coverage or cost for the care discussed. Voice a grievance against Ocular nefits, or any of its participating ocular offices, or any of the care provided by these groups or people, when their performance has not met the Member s expectations. Appeal any decisions related to patient care and treatment. Make recommendations regarding Ocular nefits Healthcare and Family Service s Member rights and responsibilities policies. Receive pertinent written and up-to-date information about Ocular nefits, the services Ocular nefits provides, the participating optometrists and ophthalmologists as well as Member rights and responsibilities. Ocular nefits CONFIDENTIAL Provider Manual 18

Statement of Provider Rights and Responsibilities Ocular nefits has established the following core concepts in its approach to a positive Provider experience: Access: Access to flexible participation options in Provider networks. Outreach: Outreach programs that lower Provider participation costs. Technology: Technology tools that increase efficiency and lower administrative costs. Feedback: Feedback that measures both Provider and Member satisfaction. Enrolled Participating Providers shall have the right to: Communicate with patients, including Members, regarding ocular treatment options. Recommend a course of treatment to a Member, even if the course of treatment is not a covered benefit, or approved by Ocular nefits. File an appeal or grievance pursuant to the procedures of Ocular nefits. Supply accurate, relevant, factual information to a Member in conjunction with a grievance filed by the Member. Object to policies, procedures, or decisions made by Ocular nefits. Enrolled Participating Providers have the following responsibilities: A Provider wishing to terminate participation with the Ocular nefits Network due to retirement, relocation, or voluntary termination must supply written notification of termination to Ocular nefits at least 60 days prior to expected final date of participation. A list of existing Ocular nefits patients currently in treatment should accompany the termination notification. other Ocular nefits patients should be referred to Ocular nefits toll-free Member number 1-855-866-2623 to find another optometrist/ophthalmologist in their area. Ocular nefits CONFIDENTIAL Provider Manual 19

Member Eligibility Verification Procedures and Services to Members Member Identification Card Health Plan members are issued identification cards regularly. Providers are responsible for verifying that Members are eligible at the time services are rendered and to determine if Members have other health insurance. Ocular nefits recommends that each provider office make a photocopy of the Member s identification card each time treatment is provided.. For additional information concerning Member Identification Cards, please contact Ocular nefits Provider Relations Department at 1-866-416-0150. Ocular nefits Eligibility Systems Enrolled Participating Providers may access Member eligibility information through: The Providers section of Ocular nefits website at www.ocularbenefits.com Ocular nefits Provider Services Department at 1-866-416-0150 Ocular nefits CONFIDENTIAL Provider Manual 20

The eligibility information received from any of the above sources will be the same information you would receive by calling Ocular nefits Provider Services Department; however, by using the website, you can get information 24 hours a day, 7 days a week, without having to wait for an available Provider Services Representative. Access to eligibility information via www.ocular nefits.com Ocular nefits website currently allows Enrolled Participating Providers to verify a Member s eligibility as well as submit claims. To access the eligibility information via Ocular nefits website, simply log on to the website at www.ocular nefits.com. Once you have entered the website, click on Providers. You will then be able to log in using your password and ID. First time users will have to self-register by utilizing their Ocular nefits Payee ID, office name and office address. Please refer to your payment remittance or contact Provider Services at 1-866-416-0150 to obtain your Payee ID. Once logged in, select eligibility look up and enter the applicable information for each Member you are inquiring about. Verify the Member s eligibility by entering the Member s date of birth, the expected date of service and the Member s identification number or last name and first initial. You are able to check on an unlimited number of patients and can print off the summary of eligibility given by the system for your records. Transportation nefits for Certain Members Members who need assistance with transportation should contact Access2Care of Kansas at 1-855-345-6943. Appointment Availability Standards Ocular nefits has established appointment time requirements for all situations to ensure members receive vision services in a time period appropriate to their health condition. Providers should ensure appointment standards are adhered to in an effort to ensure accessibility of needed services, maintain member satisfaction and reduce unnecessary use of alternative services such as an emergency room. Routine vision care must be scheduled within 21 calendar days Urgent care must be scheduled within 48 hours. Emergent care must be scheduled immediately. Ocular nefits will educate providers about appointment standards, monitor the adequacy of the process and take corrective action if required. Ocular nefits Provider Manual Annually, Ocular nefits mails (or electronically provides) a Provider Manual to every contracted ocular Provider. Ocular nefits Customer Service Numbers Ocular nefits offers Customer Service for Providers at 1-866-416-0150 Ocular nefits offers Customer Service for Members at 1-855-866-2623 Ocular nefits CONFIDENTIAL Provider Manual 21

Covered nefits KanCare Program Description KanCare is Medicaid and Children s Health Insurance Program (CHIP) managed care that integrates physical health, behavioral health and pharmacy services with certain long-term services and supports for those qualifying for certain waivers, nursing facility care, and private Intermediate Care Facility For Mental Retardation (ICF/MR) services. It covers the following populations: Temporary Assistance for Needy Families (TANF) Pregnant women Newborns Those receiving Supplemental Security Income (SSI) Those dually eligible for Medicare and Medicaid Those meeting the criteria for ICF/MR or nursing facilities Those participating in Medicaid via the Spend Down program Those participating in waivers, including: Technology Assisted Waiver Autism Waiver Serious Emotional Disturbance (SED) Waiver Physical Disability Waiver Frail Elderly Waiver Traumatic Brain Injury Waivers Developmental Disability (DD) Waiver (HCBS services for this population are not covered by MCOs at this time and remain in Fee For Service Medicaid. Amerigroup is responsible for physical health, behavioral health, vision, dental, nonemergent transportation and the Amerigroup valueadded benefits.) Please refer to the following section for a complete list of covered benefits: Error! Reference source not found. Please refer to the following section for a complete list of covered benefits: Error! Reference source not found. Missed Appointments Enrolled Participating Providers are not allowed to charge Members for missed appointments. If your office mails letters to Members who miss appointments, the following language may be helpful to include: Ocular nefits CONFIDENTIAL Provider Manual 22

We missed you when you did not come for your ocular appointment on month/date. Regular check-ups are needed to keep your eyes healthy. Please call to reschedule another appointment. Call us ahead of time if you cannot keep the appointment. Missed appointments are very costly to us. Thank you for your help. Ocular nefits offers the following suggestions to decrease the number of missed appointments. Contact the Member by phone or postcard prior to the appointment to remind the individual of the time and place of the appointment. The Centers for Medicare and Medicaid Services (CMS) interpret federal law to prohibit a Provider from billing an Ocular nefits Member for a missed appointment. In addition, your missed appointment policy for Ocular nefitsenrolled patients cannot be stricter than that of your private or commercial patients. If a(n) Ocular nefits Member exceeds your office policy for missed appointments and you choose to discontinue seeing the patient, please inform them to contact Ocular nefits for a referral to a new optometrist/ophthalmologist. Seeing the Member on a Walk-in only appointment basis is an alternative for those members who may have exceeded your standard office policy for missing scheduled appointments. If the provider wished to dismiss a patient from their practice for missed appointments or any other valid reason such as patient is abusive the dismisal needs to be in writing. Providers with benefit questions should contact Ocular nefits Provider Service directly at 1-866-416-0150. ocular services performed must be recorded in the patient record, which must be available as required by your Provider Services Agreement. Payment for Non-Covered Services Enrolled Participating Providers shall hold Members and Ocular nefits harmless for the payment of Non-Covered Services except as provided in this paragraph. Provider may bill a Member for Non-Covered Services if the Provider obtains an agreement from the Member prior to rendering such service that indicates: The services to be provided; Ocular nefits will not pay for or be liable for said Services; and Member will be financially liable for such services. Ocular nefits encourages Enrolled Participating Providers to obtain this agreement in writing, and prior to the date of service(s). Spenddown Members In some cases, the income of a family or individual exceeds the income standard to receive public assistance monies. However, their income is not sufficient to meet all medical expenses. The family group/individual must then incur a specified amount of medical expenses before they are eligible for Medicaid benefits. This process is referred to as spenddown. Claims Processed Against the Spenddown The spenddown amount will be reduced by expenses for medically necessary services of eligible beneficiaries but not allowed for in the state Medicaid plan in one of two ways. Providers will bill Ocular nefits for these services and Ocular nefitswill deduct appropriately billed amounts from the appropriate spenddown. The spenddown amount will be handled like a deductible. Ocular nefitswill automatically credit the spenddown amount when participating providers bill claims for necessary services. Billed charges apply to spenddown in date- Ocular nefits CONFIDENTIAL Provider Manual 23

processed order. Providers should bill all services regardless of whether they believe they are Medicaid-covered services so that all charges can apply toward spenddown. Providers will be reimbursed for claims submitted for QMB-covered services rendered to QMB/Medically Needy dual eligibles. These services are not affected by unmet spenddown. neficiaries Responsibility The members Managed Care Organization will identify the need for a notice to be sent to the beneficiary explaining which service(s) were used to credit the spenddown and what the new remaining spenddown amount is. These notices will be mailed to beneficiaries weekly. The beneficiary is responsible for the payment of all bills used to reduce their spenddown amount. Providers Reimbursement imized Each claim used to reduce a beneficiary s spenddown amount will be flagged to identify whether the claim would have paid if spenddown had been met. In the event a claim is submitted which exceeds the amount of spenddown remaining, all claims for the beneficiary will be reviewed. Claims that are for noncovered services or for services that would not otherwise have been paid by Medicaid will be applied to spenddown first. Processed claims that would have paid if spenddown were met will be applied to spenddown in reverse date order. Once the spenddown amount is met, the fiscal agent will adjust any remaining payable claims so that the provider may receive reimbursement from Ocular nefitsfor the services rendered. Crises Exception Process This is a situation in which a Frail/Elderly waiver member s health and welfare depends upon the requested service. There is a specific process the member s Service Coordinator will follow in order for these services to be provided. A Frail/Elderly member or their Service Coordinator will contact the provider to schedule the appropriate appointment. The provider will submit a plan of care to Ocular nefitsfor medical necessity review. Ocular nefits will inform the provider what services if any have been approved and, if approved, the provider may provide those services. Note that some of these services may not currently be covered under the Medicaid program but are determined to be medically necessary. Ocular nefits CONFIDENTIAL Provider Manual 24

Claim Submission Procedures Ocular nefits receives ocular claims infive possible formats. These formats include: 1. KMAP Electronic Submission 2. Electronic claims via Ocular nefits website (www.ocular nefits.com) 3. Electronic submission via clearinghouses 4. HIPAA Compliant 837P File 5. Paper claims via CMS-1500 Health Insurance Claim Form Electronic Claim Submission Utilizing Ocular nefits Website Enrolled Participating Providers may submit claims directly to Ocular nefits by utilizing the Provider section of our website. Submitting claims via the website is very quick and easy and is at no additional cost to Providers! It is especially easy if you have already accessed the site to check a Member s eligibility prior to providing the service. To submit claims via the website, simply log on to www.ocular nefits.com. Electronic Claim Submission via Clearinghouse Optometrists/Ophthalmologists may submit their claims to Ocular nefits via a clearinghouse such as Availity, ZirMed or Emdeon. You can contact your software vendor and make certain that they have Ocular nefits listed as a payer. Your software vendor will be able to provide you with any information you may need to ensure that submitted claims are forwarded to Ocular nefits. Ocular nefits Payer ID is OCULAR will ensure that by utilizing this unique payer ID, claims will be submitted successfully to Ocular nefits. HIPAA Compliant 837P File For Providers who are unable to submit electronically via the Internet or a clearinghouse, Ocular nefits will, on a case by case basis, work with the Provider to receive their claims electronically via a HIPAA Compliant 837P file from the Provider s practice management system. Please contact Customer Care at 1-866-416-0150 or via email at providerservices@ocularbenefits.com to inquire about this option for electronic claim submission. Paper Claim Submission claims must be submitted on an original standard CMS-1500 form or UB-04 as appropriate. Member name, identification number, and date of birth must be listed on all claims submitted. If the Member identification number is missing or miscoded on the claim form, the patient cannot be identified. This could result in the claim being returned to the submitting Provider office, causing a delay in payment. The Provider and office location information must be clearly identified on the claim. Frequently, if only the optometrist/ophthalmologist signature is used for identification, the optometrists/ophthalmologist s name cannot be clearly identified. To ensure proper claim processing, the claim form must include the following: The treating Provider s name; The location in which the treatment occurred; Ocular nefits CONFIDENTIAL Provider Manual 25

The billing (business office) location; and The treating Provider s Kansas Medicaid ID #, NPI or tax identification number (TIN). The date of service must be provided on the claim form for each service line submitted. Approved CPT or ICD-9 ocular codes as published in the current CPT book or as defined in this manual must be used to define all services. Provider must list all details for ocular codes that necessitate identification. Missing identification codes can result in the delay or denial of claim payment. Affix the proper postage when mailing bulk documentation. Ocular nefits does not accept postage due mail. This mail will be returned to the sender and will result in delay of payment. Claims should be mailed to the following address: Kansas Medical Assistance Program Office of the Fiscal nt P.O. Box 3571 Topeka, KS 66601-3571 Claims Adjudication and Payment Ocular nefits system adjudicates all claims automatically twice per month. It also has the ability to automatically update individual and family claim history, perform claim payment calculations, calculate and update copayment/deductible accumulations, and track benefit maximums and frequency limits, where appropriate. The Claim Adjudication Module (CAM) serves as Ocular nefits primary claims processing tool. Ocular nefits Claims Adjudication Module imports the data, edits the data for completeness and correctness, analyzes the data for clinical and coding correctness/appropriateness, and audits against product and benefit limits. CAM also will review claims/services that require preauthorization s, and automatically match the claim/service to the appropriate Member record for efficient claims processing. Once all CAM edits are complete, claims are priced, a remittance summary is printed, and a check or EFT payment is generated. Coordination of nefits (COB) When Ocular nefits is the secondary insurance carrier, a copy of the primary carrier s Explanation of nefits (EOB) must be submitted with the claim. For electronic claim submissions, the payment made by the primary carrier must be indicated in the appropriate COB field. When a primary carrier s payment meets or exceeds a Provider s contracted rate or fee schedule, Ocular nefits will consider the claim paid in full and no further payment will be made on the claim. Filing Limits The timely filing requirement for the Kansas Program is 180 calendar days from the date of service and receipt of claim. Ocular nefits determines whether a claim has been filed timely by comparing the date of service to the receipt date applied to the claim when the claim is received. If the span between these two dates exceeds the time limitation, the claim is considered to have not been filed timely. Ocular nefits CONFIDENTIAL Provider Manual 26

Receipt and Audit of Claims In order to ensure timely, accurate remittances to each optometrist and ophthalmologist, Ocular nefits performs an edit of all claims upon receipt. This edit validates Member eligibility, procedure codes, and Provider identifying information. A Reimbursement Analyst dedicated to Kansas ocular offices analyzes any claim conditions that would result in non-payment. When potential problems are identified, your office may be contacted and asked to assist in resolving this problem. Please feel free to contact Ocular nefits Provider Services at 1-866-416-0150 with any questions you may have regarding claim submission or your remittance. Each Enrolled Participating Provider office receives an explanation of benefit report with their remittance. This report includes Member information and an allowable fee by date of service for each service rendered during the period. If an optometrist/ophthalmologist wishes to appeal any reimbursement decision, they need to submit an appeal in writing, along with any necessary additional documentation within 30 days form the decision of the request to: Ocular nefits Ocular nefits - Appeals PO Box 1616 Milwaukee, WI 53201 Ocular nefits will have 14 days to respond in writing to the optometrist and ophthalmologist with outcome of the appeal. This notice will contain the information necessary to appeal this decision. To validate accuracy, on a monthly basis Ocular nefits will perform an audit of a statistically significant sample of all the claim forms entered and adjudicated in the prior month. Ocular nefits CONFIDENTIAL Provider Manual 27

Ocular nefits CONFIDENTIAL Provider Manual 28

Important Notice for Submitting Paper Authorizations and Claims In order to maintain HIPAA compliance, effective with claims received October 1, 2010, only CMS-1500 and UB-04 claim forms will be accepted when submitting claims and pre-authorizations. other forms will not be accepted and will result in a rejection of the claim or pre-authorization request. Additionally, when making a correction to a previously submitted claim, please send it clearly marked Corrected Claims on CMS-1500 or UB-04 Claim Forms to the Appeals mailbox. Please contact the Provider service toll free number if you have questions. If you are in need of the current forms, please visit the AMA website at www.ama-assn.org for ordering information. Clean claims include the following: Member name Member date of birth Member ID number Treating Provider Payee (Billing Provider) Tax ID number Date of service Location of service Procedure code Claims with missing or invalid information may be rejected and returned to the Provider. Clean authorizations include the following: Member name Member date of birth Member ID number Treating Provider Payee and location Procedure code Authorizations with missing or invalid information may be rejected and returned to the Provider Ocular nefits CONFIDENTIAL Provider Manual 29

UB-04 Claim Form Ocular nefits CONFIDENTIAL Provider Manual 30

CMS-1500 Claim Form Ocular nefits CONFIDENTIAL Provider Manual 31

Inquiries, Grievances and Appeals Ocular nefits is committed to providing high quality ocular services to all Members. As part of this commitment, Ocular nefits supports a Grievances and appeals protocol that assures that all Members have every opportunity to exercise their rights to a fair and expeditious resolution to any and all inquiries, grievances and appeals. Toward that end, Ocular nefits has developed a procedure to meet the following goals: To ensure that Members receive a fair, just and speedy resolution to inquiries, grievances and appeals; To allow Members to be treated with dignity and respect at all levels of the grievances and appeals resolution process; To inform Members of their full rights as they relate to grievances and appeals resolution, including their rights of appeal at each step in the process; To have Member grievances and appeals resolved in a satisfactory and acceptable manner within the Ocular nefits protocol; To comply with all regulatory guidelines and policies with respect to Member inquiries, grievances and appeals; and To efficiently track the resolution of Provider related grievances, so as to be able to track continuing unacceptable patterns of care over time. Ocular nefits provides customer service, the primary purpose of which is to insure Member access to information, services, and assistance on issues affecting their coverage. The designated grievance coordinator is dedicated to the expedient, satisfactory resolution of Member inquiries, grievances and appeals. Inquiry A request from a member for information that would clarify health plan policy, benefits, procedures or any aspect of health plan function but does not express dissatisfaction.member Service Representatives are trained to respond in a prompt and courteous fashion, and to resolve any surrounding issues in an expedient manner. Member Service Representatives have at their disposal all internal resources of Ocular nefits to insure prompt resolution of any problems. If specific corrective action is requested by the Member or determined to be necessary by Ocular nefits, then the inquiry is upgraded to a grievance. Grievances A grievance is an expression of dissatisfaction about any matter other than an action. Possible subjects for grievances include but are not limited to, the quality of care or services provided and aspects of interpersonal relationships such as rudeness of a provider or employee, or failure to respect the member s rights. When a grievance is received by any representative of Member Services, either orally or in writing, it will be forwarded to the Ocular nefits Grievance Representative immediately.the Grievance Representative then assigns the appropriate trending code and will make every effort to resolve the grievance on an immediate basis, (within 24 hours whenever possible). The Grievance Representative will handle the grievance themselves, or identify the appropriate Ocular nefits personnel, and forward the grievance to that department requesting resolution within three days. The grievance Representative will do appropriate followup as needed to ensure expedient handling and to keep the Member informed as to the stage of investigation and resolution. Resolutions to grievances will be sent to the member in writing within 30 calendar days or adhere to the more restrictive requirement of the Plan or State. Ocular nefits CONFIDENTIAL Provider Manual 32

Appeals The address to file a Grievance: Ocular nefits of Kansas Grievance PO Box 1448 Milwaukee, WI 53201 Member Appeals Members must file an appeal within 30 days following the date the denial letter was mailed by Ocular nefits. Member requests for a fair hearing can be submitted through a written or verbal request. Written requests should be sent to: Central Appeals Processing Amerigroup Kansas P.O. Box 62429 Virginia ach, VA 23466-2429 For verbal requests, please contact Amerigroup s Member Services Department at 1-800-600-4441.. Provider Appeal Procedures In the operation of the program, differences may develop between Ocular nefits and the provider concerning the decision regarding the Prior Authorization Option and payment for service. Since many of these problems result from misunderstanding of processing policy, service coverage or payment levels, thorough acquaintance with Ocular nefits will help prevent such problems. To request an appeal, the provider should write: Ocular nefits of Kansas Appeals PO Box 1448 Milwaukee, WI 53201 Fair Hearing Procedures If a provider disagrees with a decision Ocular nefits has made on a claim, the provider has the right to request a fair hearing within thirty days of the notification letter. provider appeal rights must be ehausted prior to requesting a fair hearing. There is not a required form but the request needs to be sent in writing to: Office Of Administrative Hearings 1020 S. Kansas Ave. Topeka, KS 66612-1327 Ocular nefits CONFIDENTIAL Provider Manual 33

Health Insurance Portability and Accountability Act (HIPAA) As a healthcare Provider, if you transmit any health information electronically your office is required to comply with all aspects of the HIPAA regulations that have gone/will go into effect as indicated in the final publications of the various rules covered by HIPAA. Ocular nefits has implemented various operational policies and procedures to ensure that it is compliant with the Privacy Standards as well. Ocular nefits also intends to comply with all Administrative Simplification and Security Standards by their compliance dates. One aspect of our compliance plan will be working cooperatively with Providers to comply with the HIPAA regulations. The Provider and Ocular nefits agree to conduct their respective activities in accordance with the applicable provisions of HIPAA and such implementing regulations. When contacting Provider Services, Providers will be asked to provide their TAX ID or NPI number. When calling regarding Member inquiries, Providers will be asked to provide specific Member identification such as Member ID/SSN, date of birth, name, and/or address, In regulation to the Administrative Simplification Standards, you will note that the benefit tables included in this Provider manual reflect the most current coding standards (CDT-2010) recognized by the ADA. Effective the date of this manual, Ocular nefits will require Providers to submit all claims with the proper CDT codes listed in this manual. In addition, all paper claims must be submitted on the current approved CMS 1500 or UB04 claim form. Note: Copies of Ocular nefits HIPAA policies are available upon request by contacting Ocular nefits Provider Services at 1-866-416-0150 or via e-mail at providerservices@ocularbenefits.com Ocular nefits CONFIDENTIAL Provider Manual 34

Credentialing As required by law, any optometrist/ophthalmologist who is interested in participation with Ocular nefits is invited to apply and submit a credentialing application form for review by the Ocular nefits Credentialing Committee. Ocular nefits, in conjunction with the Plan, has the sole right to determine which optometrists/ophthalmologists it shall accept and continue as Participating Providers. Providers who seek participation in any Ocular nefits Managed Care network must be credentialed prior to participation in the network. Ocular nefits will not differentiate or discriminate in the treatment of Providers seeking credentialing on the basis of race, ethnicity, sex, age, national origin or religion. applications reviewed by Ocular nefits must satisfy NCQA and/or URAC standards of credentialing, as they apply to Ocular services. The Credentialing Committee has the discretion and authority to accept an application without restrictions. If the Credentialing Committee determines that an application should be accepted with restriction or declined, it shall recommend the appropriate action to the Executive Subcommittee for approval. In reviewing an application, the Credentialing Committee may request further information from the applicant. The Credentialing Committee may table an application pending the outcome of an investigation of the applicant by a hospital, licensing board, government agency or any other organization or institution; or recommend any other action it deems appropriate. Adverse credentialing recommendations of the Credentialing Committee can be forwarded to the Executive Subcommittee for final approval, subject to any appeal following such approval offered to and accepted by the applicant. If the applicant accepts the opportunity for a reconsideration review, the Credentialing Committee will review all original documents, as well as, any additional information submitted for the reconsideration review. If an applicant accepts the opportunity to appeal the Credentialing Committee s recommendation, the Peer Review Committee will complete the review. Any acceptance of an applicant is conditioned upon the applicant s execution of a participation agreement with Ocular nefits. Amerigroup retains the ultimate responsibility for Ocular nefits credentialing process and final credentialing decisions. The Plan is notified of any terminations or disciplinary actions. Ocular nefits CONFIDENTIAL Provider Manual 35

Member Access Appointment Availability Standards Ocular nefits has established appointment time requirements for all situations to ensure that Members receive ocular services in a time period that is appropriate to their health condition. Providers should ensure that appointment standards are adhered to in an effort to ensure accessibility of needed services, maintain Member satisfaction and reduce unnecessary use of alternative services such as an emergency room. In office wait times must not exceed 45 minutes. Appointment/Waiting Times: Usual and customary not to exceed three (3) weeks for regular appointments and 48 hours for urgent care. Ocular nefits will educate Providers about appointment standards, monitor the adequacy of the process and take corrective action if required. Emergency Services Ocular nefits covers emergency services when: Participating provider shall be reimbursed for services rendered without prior approval, where a prudent layperson, acting reasonably, would have believed that an emergency medical condition existed. In addition to the private office, medical services may be provided in the home, a hospital, approved independent clinic, nursing facility, residential treatment center and elsewhere. Services should be provided in any appropriate setting, governed by medical necessity and not by the convenience or desires of the members or providers of services. Medical services provided in an inpatient or outpatient hospital setting or elsewhere outside the provider s office setting are subject to all applicable State and facility regulations. Out of Network Out-of-Network medical vision services are limited to emergency services only. Emergency medical care consists of treatment to alleviate a medical emergency. No other services may be provided. Compensation for nonparticipating providers is limited to the State Medicaid/Health Plan fee schedule or reimbursement rate for palliative treatment and appropriate diagnostic evaluation wherever possible. If the provider will not accept Medicaid, payment will reflect an agreed upon rate with provider without any additional member responsibility. Claims submitted by nonparticipating providers are subject to retrospective review. No payment is made until all appropriate clinical documentation has been reviewed by the medical consultant. Ocular nefits CONFIDENTIAL Provider Manual 36

Utilization Management Treatment Decisions Introduction Reimbursement to optometrists and ophthalmologists for ocular treatment rendered can come from any number of sources such as individuals, employers, insurance companies and local, state or federal government. The source of dollars varies depending on the particular program. For example, in traditional insurance, the optometrist and ophthalmologist reimbursement is composed of an insurance payment and a patient coinsurance payment. This Kansas State Legislature annually appropriates or budgets the amount of dollars available for reimbursement to optometrist and ophthalmologists for treating Kansas Members. Since there are no patient co-payment, these dollars represent all the reimbursement available to the optometrist and ophthalmologist. The fair and appropriate distribution of these limited funds is critical. Community Practice Patterns To ensure fair and appropriate reimbursement, Ocular nefits has developed a philosophy of Utilization Management that recognizes the fact that there exists, as in all healthcare services, a relationship between the optometrist s and ophthalmologist s treatment planning, treatment costs and treatment outcomes. The dynamics of these relationships, in any region, are reflected by the community practice patterns of local optometrists and ophthalmologists and their peers. With this in mind, Ocular nefits Utilization Management Programs are designed to ensure the fair and appropriate distribution of healthcare dollars as defined by the regionally based community practice patterns of local optometrists and ophthalmologists and their peers. utilization management analysis, evaluations and outcomes are related to these patterns. Ocular nefits Utilization Management Programs recognize that there is individual optometrist and ophthalmologist variance within these patterns among a community of optometrists and ophthalmologists and accounts for such variance. Also, specialty optometrists and ophthalmologists are evaluated as a separate group and not with general optometrists and ophthalmologists since the types and nature of treatment may differ. Evaluation Ocular nefits Utilization Management Programs evaluate claims submissions in such areas as: Diagnostic and preventive treatment Patient treatment planning and sequencing; s of treatment; Treatment outcomes; and Treatment cost effectiveness. Results With the objective of ensuring the fair and appropriate distribution of these budgeted Ocular nefits dollars to optometrists and ophthalmologists, Ocular nefits Utilization Management Programs helps identify optometrists and ophthalmologists whose patterns show significant deviation from the normal practice patterns of the community of their peers (typically less than 5% of all optometrists and ophthalmologists). Ocular nefits is contractually obligated to report suspected fraud, abuse or misuse by Members and Participating Ocular Providers to the Ocular nefits Office of the Inspector General. Ocular nefits CONFIDENTIAL Provider Manual 37

Non-Incentivization Policy It is Ocular nefits practice to ensure our contracted Providers are making treatment decisions based upon individual Members medical necessity. Providers are never offered, nor will they ever accept, any kind of financial incentives or any other encouragement to influence their treatment decisions. Ocular nefits Utilization Management Department bases their decision making only on appropriateness of care, service, and existence of coverage. Ocular nefits does not reward practitioners or other individuals for issuing denials of coverage or care. If financial incentives exist for Utilization Management decision makers, they do not include or encourage decisions that result in underutilization. Fraud and Abuse Ocular nefits is committed to detecting, reporting and preventing potential fraud and abuse. Fraud and abuse are defined as: Fraud: Intentional deception or misrepresentation made by a person with knowledge that the deception could result in some unauthorized benefit to himself or some other person. It includes any act that constitutes fraud under federal or state law. Abuse: Abuse means Provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary cost to the Medicaid program, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care. It also includes recipient practices that result in unnecessary cost to the Medicaid program. Provider Fraud: Provider practices that are inconsistent with sound fiscal, business or medical practices, and result in unnecessary cost to the program, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care. It also includes recipient practices that result in unnecessary cost to the program. Deficit Reduction Act of 2005: The False Claims Act On February 8, 2006, President Bush signed into law the Deficit Reduction Act of 2005 (DRA), a bill designed to reduce federal spending on entitlement programs over five years. The DRA requires that any entity that receives or makes annual Medicaid payments of at least $5 million establish written policies for its employees, management, contractors and agents regarding the False Claims Act (the FCA ). The FCA allows private persons to bring a civil action against those who knowingly submit false claims. If there is a recovery in the case brought under the FCA, the person bringing suit may receive a percentage of the recovered funds. For the party found responsible for the false claim, the government may seek to exclude them from future participation in federal healthcare programs or impose additional obligations against the individual. For more information about the False Claims Act go to: www.taf.org Ocular nefits is contractually obligated to report suspected fraud, waste or abuse by Members and Participating Ocular Providers. Ocular nefits CONFIDENTIAL Provider Manual 38

Random Chart Audits Ocular nefits publishes standardized record keeping criteria that is state specific and compliant with the requirements of The National Committee for Quality Assurance. Ocular nefits expectation is that every participating medical office is compliant with these protocols. Likewise, Ocular nefits expects that every office will provide quality medical services in a cost effective manner in keeping with the stated or implied standards of care in the community and medical profession nationwide. The offices will submit claims for services in an accurate and ethical fashion reflecting the appropriate level and scope of services performed. One method used on a limited basis to assure compliance with these conditions and expectations is to require Providers to supply upon request, complete copies of patient medical charts. The charts are then reviewed by the appropriately trained staff, to document the rate of compliance with the charting requirements as well as the accuracy of the medical claims submitted for payment. The first part of the audit will consist of the charts being reviewed for compliance with the stated record keeping requirements, utilizing a standardized audit tool (attached). The charts are reviewed and a composite score determined. Offices with scores above 80% are considered as passing the audit but a corrective action letter is sent to them so that they are aware of the areas that need improvement. Offices that receive a score of 95% or greater are exempt from the audit the following year. Offices with scores less than 80% will have a corrective action letter sent, and are re-reviewed for compliance within the next ninety days. Offices that do not cooperate with improving their scores are subject to sanction up to and including termination from the panel. The second portion of the audit consists of a billing reconciliation whereby the patient treatment notes are compared to the actual claims submitted for payment by each medical office. The records are analyzed to determine if the patient record documents the performance of all the medical services that have been submitted for payment. Any services not documented are recouped, and the records are referred to the Special Investigations Unit for a complete investigation and necessary corrective action. Results of both parts of the audit are entered into a tracking data base at Ocular nefits and then reported back to each office in a summary of finding format. Results are reported back to the Health Plans on an annual basis. Time Frame For charts that are requested and not received within 10 business days, the first request for records are followed up with a second request letter and a telephone call placed to the Provider s office. The Provider is reminded of the contractual obligation to participate with Ocular nefits Quality initiatives. If a third request letter is warranted, the Quality Specialist will refer the Provider to the Peer Review Committee for noncompliance with the record request. The Peer Review Committee may send a letter including information about possible credentialing sanctions imposed for noncompliance with the record request. Ocular nefits CONFIDENTIAL Provider Manual 39

Medical Necessity The written standards utilized in the process of benefit determination will include the state Medicaid guidelines, the American Academy of Ophthalmology (AAO) guidance, the American Academy of Optometry (AOA) guidance, educational materials published by the Health Association of America, International Claims Association, plan benefit description documents as well as the information contained in the current Code of Medical Terminology published by the American Medical Association and the Medical Prevailing Healthcare Charges System, published by the Health Insurance Association of America. Ocular nefits refers any questionable services for evaluation by the Peer Review Committee or independent peer review if requested to do so by treating provider. Criteria are reviewed on a yearly basis as part of the Utilization Management Program annual review. The determination of medical necessity is necessary for prior authorization, concurrent reviews or retrospective review for claims processing. The Medical Consultant or licensed physician, as required by plan/state, will consider all submitted documentation in the final determination of medical necessity. They will also consider appropriateness of the requested service, the member s individual circumstances and the applicable contract language concerning benefits and exclusions. UR criteria may not be the sole basis for the decision. In Kansas, Ocular nefits complies with the definition of medical necessity as outlined in K.A.R. 30-5-58(ooo). Medical necessity - means that a health intervention is an otherwise covered category of service, is not specifically excluded from coverage, and is medically necessary, according to all of the following criteria: a. Authority. The health intervention is recommended by the treating physician and is determined to be necessary by the secretary or the secretary s designee. b. Purpose. The health intervention has the purpose of treating a medical condition. c. Scope. The health intervention provides the most appropriate supply or level of service, considering potential benefits and harms to the patient. d. Evidence. The health intervention is known to be effective in improving health outcomes. For new interventions, effectiveness shall be determined by scientific evidence as provided herein. For existing interventions, effectiveness shall be determined as provided in 30-5-58(ooo)(4). e. Value. The health intervention is cost-effective for this condition compared to alternative interventions, including no intervention. Cost-effective shall not necessarily be construed to mean lowest price. An intervention may be medically indicated and yet not be a covered benefit or meet the regulation s definition of medical necessity. f. Interventions that do not meet this regulation s definition of medical necessity may be covered at the choice of the secretary or the secretary s designee. An intervention shall be considered cost effective if the benefits and harms relative to costs represent an economically efficient use of resources for patients with this condition. In the application of this criterion to an individual case, the characteristics of the individual patient shall be determinative. Please reference K.A.R. 30-5-58(ooo) for more information and other definitions related to the above. Regarding reference to the secretary or the secretary s designee, note that Amerigroup Kansas, Inc. has entered into a contract with the Kansas Department of Health and Environment (KDHE) to manage care for KanCare program members. Amerigroup delegates medical necessity reviews for routine and medical vision services to Ocular nefits. The fact that a physician has prescribed, recommended or approved medical or allied care, goods or services does not, in itself, make such care, goods or services medically necessary or a medical necessity. In the event that the medical consultant is unable to determine medical necessity due to the medical implications of treatment, the medical consultant will refer such review to the medical director of the Plan. Ocular nefits CONFIDENTIAL Provider Manual 40

Utilization Review It is expected that procedures performed will comply with these guidelines and exceptions are minimal. Ocular nefits utilizes the current American Optometric Association s (AOA) Codes for Optometry and the American Academy of Ophthalmology (AAO) in rendering benefit decisions. Generally accepted medical practice guidelines are applied in all decisions in conjunction with each State s and Plan requirements. The specifics of criteria applicable are outlined in detail within the Provider Manual. Clinical Guidelines Clinical guidelines are utilized to assist in the day to day and triage of services requested for members. While the guidelines are a great asset in determining medical care for a member, they are not an absolute standard that Ocular nefits is bound to. Numerous factors can influence what type of medical care is appropriate for a member and if a member needs care different from the clinical guidelines, the Medical Director has the ultimate authority on how to best plan the treatment for a member. Criteria is reviewed objectively and based on medical evidence that is consistent with national Medicaid coverage guidelines, as well as, the American Academy of Ophthalmology Clinical Guidelines and the American Optometric Association Clinical Guidelines, the state Medicaid guidelines, Health Plan requirements and Member benefit level description. A provider may request a member to see an ophthalmologist if the provider feels it is within the member s best interest even in cases where a member would normally be triaged to an Optometrist. The clinical guidelines are reviewed annually with updates and revisions added to policy as necessary. Clinical guidelines can be obtained by logging onto www.ocular benefits.com and logging into your provider account. You can also contact Provider Services at 1-866-416-0150 to obtain a copy of the clinical guidelines. Peer to Peer Requests At any time you have a question regarding a clinical criteria guideline or a clinical decision made on an authorization request, you have the right to speak to a Medical Reviewer. You can contact a Medical Reviewer by calling Provider Services at 1-866- 416-0150. Ocular nefits CONFIDENTIAL Provider Manual 41

Prior Authorization, Retrospective Review, and Documentation Requirements Ocular nefits must make a decision on a pre-service non-urgent request or within 5 calendar days from the date Ocular nefits receives this request, provided all information is complete. If documentation is not included, Ocular nefits has up to 14 calendar days to process your request. If Ocular nefitsdenies the approval for some or all of the services requested, Ocular nefitswill send the recipient a written notice of the reasons for the denial(s) and will tell the Member that he or she may appeal the decision. Procedures Requiring Prior Authorization Ocular nefitshas specific ocular utilization criteria as well as a prior authorization and retrospective review process to manage the utilization of services. Consequently, Ocular nefits operational focus is on assuring compliance with its utilization criteria. One method used on a limited basis to assure compliance is to require Providers to supply specified documentation prior to authorizing payment for certain procedures. Services that require prior authorization should not be started prior to the determination of coverage (approval or denial of the prior authorization) for non-emergency services. Non-emergency treatment started prior to the determination of coverage will be performed at the financial risk of the provider office. If coverage is denied, the treating optometrist/ophthalmologist will be financially responsible and may not balance bill the Member, the State of Kansas or any agents, and/or Ocular nefits. Prior authorizations will be honored for 30 days from the date they are issued. An approval does not guarantee payment. The Member must be eligible at the time the services are provided. The Provider should verify eligibility at the time of service. Requests for prior authorization may be sent with the appropriate documentation via our web portal, fax at 800.310.9871 or a call to our provider service line. Any claims or Prior Authorizations submitted without the required documentation will be denied and must be resubmitted to obtain reimbursement. The basis for granting or denying approval shall be whether the item or service is medically necessary, whether a less expensive service would adequately meet the Member s needs, and whether the proposed item or service conforms to commonly accepted standards in the ocular community. During the prior authorization process it may become necessary to have your patient clinically evaluated. If this is the case, you will be notified of a date and time for the examination. It is the responsibility of the participating optometrist/ophthalmologist to ensure attendance at this appointment. Patient failure to keep an appointment will result in denial of the treatment. Retrospective Review Services that would normally require a Prior Authorization, but are performed without prior approval, will be subject to a Retrospective Review. Retrospective Review is based on the criteria utilized in the prior authorization process to determine medical necessity and appropriateness of care. Ocular nefits covers emergency services when authorized to a participating provider or to another participating representative and where a prudent layperson, acting reasonably, would have believed that an emergency medical condition existed. Requests for retrospective review must be received within 30 days of the date of service. Ocular nefits will make the retrospective review determinations within 30 days of the receipt of the request. Once determination has been made on a retrospective review, the request along with the claim is forwarded for processing and adjudication. The determination shall not retrospectively deny coverage for services when prior approval has been given unless the approval was based on fraudulent, materially inaccurate, or misrepresented information by the covered person, authorized person or provider. If a pattern of abuse is noted for any one practice, a written request for corrective action is sent. Ocular nefits CONFIDENTIAL Provider Manual 42

nefit Plan Detail Report Product: Kan Product Code Code Description Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan 00103 00140 00142 00144 00145 00147 00148 00300 ANESTHESIA RECONSTRUCTIVE PROCEDURES OF EYELID ANESTHESIA FOR PROCEDURES ON EYE; NOS ANESTHESIA FOR PROCEDURES ON EYE; LENS SURGERY ANESTHESIA PROCEDURES ON EYE; CORNEAL TRANSPLANT ANESTHESIA PROCEDURES EYE; VITREORETINAL SURGERY ANESTHESIA FOR PROCEDURES ON EYE; IRIDECTOMY ANESTHESIA FOR PROCEDURES ON EYE; OPHTHALMOSCOPY ANES-INTEG SYST MUSC&NERV HEAD NECK TRUNK;NOS 009 SPEND DOWN ADJUSTMENT 0192T 022 023 024 ANT SEGMENT INSERTION DRAINAGE W/O RESERVOIR EXT SKILLED NURSING FACILITY PROSPECTIVE PAYMENT SYSTEM Home health prospective payment system Inpatient rehabilitation facility prospective payment system 100 ALL INCL R&B/ANC 101 ALL INCL R&B 110 ROOM-BOARD/PVT 11042 11043 11044 11045 DEBRIDEMENT; SKIN AND SUBCUTANEOUS TISSUE DEBRIDEMENT; SKIN SUBCUTANEOUS TISSUE AND MUSCLE DEBRIDEMENT; SKIN SUBCUT TISSUE MUSCLE&BONE DBRDMT SUBCUTANEOUS TISSUE EA ADDL 20 SQ CM 11046 DBRDMT M&/F EA ADDL 20 SQ CM 11047 DEBRIDEMENT BONE EA ADDL 20 SQ CM/< 111 MED-SUR-GY/PVT services require Prior Authorization

Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan 11100 11101 BX SKIN SUBQ TISSUE &/ MUCOUS MEMBRANE; 1 LESION BX SKIN SUBQ TISSUE &/ MUCOUS MEMBRANE; EA ADD 112 OB/PVT 11200 11201 REMOVAL SKIN TAGS ANY AREA;TO & INCL 15 LESION REMOVAL SKIN TAGS ANY AREA;EA ADD 10 LESIONS 113 PEDS/PVT 114 PSYCH/PVT 11440 11441 11442 11443 11444 11446 EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M 0.5CM/< EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M 0.6-1.0CM EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M 1.1-2.0CM EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M 2.1-3.0CM EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M 3.1-4.0CM EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M >4.0CM 115 HOSPICE/PVT 116 DETOX/PVT 11640 11641 11642 11643 11644 11646 EXC MAL LES MARG FCE ERS EYELD NSE LPS; 0.5 CM/< EXC MAL LES MARG FCE ERS EYELD NSE LP;0.6-1.0 CM EXC MAL LES MARG FCE ERS EYELD NSE LP;1.1-2.0 CM EXC MAL LES MARG FCE ERS EYELD NSE LP;2.1-3.0 CM EXC MAL LES MARG FCE ERS EYELD NSE LP;3.1-4.0 CM EXC MAL LES MARG FCE ERS EYELD NSE LP;OVR 4.0 CM 117 ONCOLOGY/PVT 118 REHAB/PVT 119 OTHER/PVT 120 ROOM-BOARD/SEMI 12011 SIMPL REPR FACE EARS NOSE&/MUCOUS MEMB; < 2.5 CM

Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan 12013 12014 12015 12016 12017 12018 12020 12021 12051 12052 12053 12054 12055 12056 12057 SIMPL REPR FACE ERS NOSE&/MUCOUS MEMB;2.6-5.0 CM SIMPL REPR FCE ERS NOSE&/MUCOUS MEMB; 5.1-7.5 CM SIMPL REPR FCE ERS NOSE&/MUCOUS MEMB;7.6-12.5 CM SIMPL REPR FCE ERS NSE&/MUCOUS MEMB;12.6-20.0 CM SIMPL REPR FCE ERS NSE&/MUCOUS MEMB;20.1-30.0 CM SIMPL REPR FACE ERS NOSE&/MUCOUS MEMB; > 30.0 CM TX SUPERFICIAL WOUND DEHISCENCE; SIMPLE CLOSURE TX SUPERFICIAL WOUND DEHISCENCE; W/PACKING LAYER CLOS WNDS FACE EARS NOSE&/LIPS; < 2.5 CM LAYER CLOS WNDS FACE EARS NOSE&/LIPS; 2.6-5.0 CM LAYER CLOS WNDS FACE EARS NOSE&/LIPS; 5.1-7.5 CM LAYER CLOS WNDS FCE EARS NOSE&/LIPS; 7.6-12.5 CM LAYER CLOS WNDS FCE EARS NOSE&/LPS; 12.6-20.0 CM LAYER CLOS WNDS FCE EARS NOSE&/LPS; 20.1-30.0 CM LAYER CLOS WNDS FACE EARS NOSE&/LIPS; > 30.0 CM 121 MED-SUR-GY/2BED 122 OB/2BED 123 PEDS/2BED 124 PSYCH/2BED 125 HOSPICE/2BED 126 DETOX/2BED 127 ONCOLOGY/2BED 128 REHAB/2BED 129 OTHER/2BED 130 ROOM-BOARD/3&4BED 131 MED-SUR-GY/3&4BED

Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan 13150 13151 13152 13153 13160 REPR CMPLX EYELIDS NOSE EARS&/LIPS; < 1.0 CM REPR CMPLX EYELIDS NOSE EARS&/LIPS; 1.1-2.5 CM REPR CMPLX EYELIDS NOSE EARS&/LIPS; 2.6-7.5 CM REPR CMPLX EYELDS NSE EARS&/LPS;EA ADD 5 CM/LESS SEC CLOS SURGICAL WOUND/DEHIS EXTENSIVE/COMP 132 OB/3&4BED 133 PEDS/3&4BED 134 PSYCH/3&4BED 135 HOSPICE/3&4BED 136 DETOX/3&4BED 137 ONCOLOGY/3&4BED 138 REHAB/3&4BED 139 OTHER/3&4BED 140 ROOM-BOARD/PVT/DLX 14060 14061 ADJ TISS TRANS EYELDS NOSE&/LIPS; 10 SQ CM/LESS ADJ TISS TRANS EYELDS NOSE&/LIPS;10.1-30.0 SQ CM 141 MED-SUR-GY/DLX 142 OB/DLX 143 PEDS/DLX 144 PSYCH/DLX 145 HOSPICE/DLX 146 DETOX/DLX 147 ONCOLOGY/DLX 148 REHAB/DLX 149 OTHER/DLX 150 ROOM-BOARD/WARD

Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan 15004 PREP SITE F/S/N/H/F/G/M/D GT 1ST 100 SQ CM/1PCT 151 MED-SUR-GY/WARD 15120 15121 SPLT AGRFT F/S/N/H/F/G/M/D GT 1ST 100 CM/</1% SPLT AGRFT F/S/N/H/F/G/M/D GT EA 100 CM/EA 1 % 152 OB/WARD 15260 FULL THICK GFT NOSE EARS EYELDS&/LPS; 20 SQ CM/< 153 PEDS/WARD 154 PSYCH/WARD 155 HOSPICE/WARD 15576 FORM DIR PEDICLE W/WO TRANSF;EYELDS NSE EARS/LIP 156 DETOX/WARD 15630 DELAY FLAP/SECTIONING FLAP;EYELD NOSE EARS/LIPS 157 ONCOLOGY/WARD 158 REHAB/WARD 15820 BLEPHAROPLASTY LOWER EYELID; 15821 BLPHPLSTY LOWER EYELID; W/EXT HERNIATED FAT PAD 15822 BLEPHAROPLASTY UPPER EYELID; 15823 BLPHPLSTY UPPER EYELID; W/XCESS SKIN WT DOWN LID 159 OTHER/WARD 160 R&B 164 R&B/STERILE 167 R&B/SELF 169 R&B/OTHER 170 NURSERY 17000 17003 DESTRUC BEN/PREMALIG LES OTH THAN SKN TAG; 1 LES DESTRUC BEN/PREMALIG LES OTH THN SKN TAG;2-14 EA

Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan 17004 DESTRUC BEN/PREMALIG OTH THN SKIN TAGS 15/> LES 171 NURSERY/LEVEL I 17106 17107 17108 17110 17111 DESTRUC CUT VASCULAR PROLIFERAT LES; < 10 SQ CM DESTRUC CUT VASC PROLIFERAT LES; 10.0-50.0 SQ CM DESTRUC CUT VASC PROLIFERAT LES; > 50.0 SQ CM DESTRUC FLAT WARTS MOLLUSC CONTAG/MILIA; UP 14 DESTRUC FLAT WARTS MOLLUSC CONTAG/MILIA; 15/>LES 172 NURSERY/LEVEL II 17250 17280 17281 17282 17283 17284 17286 CHEMICAL CAUTERIZATION OF GRANULATION TISSUE DESTRUC MAL LES FCE ERS EYELD NSE LPS; 0.5 CM/< DESTRUC MAL LES FCE ERS EYELD NSE LPS;0.6-1.0 CM DESTRUC MAL LES FCE ERS EYELD NSE LPS;1.1-2.0 CM DESTRUC MAL LES FCE ERS EYELD NSE LPS;2.1-3.0 CM DESTRUC MAL LES FCE ERS EYELD NSE LPS;3.1-4.0 CM DESTRUC MAL LES FCE ERS EYELD NSE LPS; > 4.0 CM 173 NURSERY/LEVEL III 17304 17305 17306 17307 17310 MOHS SURG; 1 STAGE FRESH TISS TECH UP 5 SPECIMEN MOHS SURG; 2 STAGE FIX/FRESH TISS UP 5 SPECIMEN MOHS SURG; 3 STAGE FIX/FRESH TISS UP 5 SPECIMEN MOHS SURG; ADD STAGE UP 5 SPECIMEN EA STAGE MOHS SURG; EA ADD AFTER 1ST 5 SPECIMEN ANY STAGE 174 NURSERY/LEVEL IV 179 NURSERY/OTHER 180 LEAVE OF ABSENCE 182 LOA/PT CONV CHGS BILLABLE 183 LOA/THERAP

Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan 184 LOA/ICF/MR 185 LOA/NURS HOME 189 LOA/OTHER 190 SUBACUTE 191 SUBACUTE/LEVEL I 192 SUBACUTE/LEVEL II 193 SUBACUTE/LEVEL III 194 SUBACUTE/LEVEL IV 199 SUBACUTE/OTHER 200 INTENSIVE CARE 201 ICU/SURGICAL 202 ICU/MEDICAL 203 ICU/PEDS 204 ICU/PSTAY 206 ICU/INTERMEDIATE 207 ICU/BURN CARE 208 ICU/TRAMA 209 ICU/OTHER 210 CORONARY CARE 211 CCU/MYO INFARC 212 ALL INCL ANCIL 212 CCU/PULMONARY 213 CCU/TRANSPLANT 214 CCU/INTERMEDIATE 219 CCU/OTHER 220 SPECIAL CHARGES

Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan 221 ADMIT CHARGE 222 TECH SUPPT CHG 223 UR CHARGE 224 LATE DISCH/MED NEC 229 OTHER SPEC CHG 230 NURSING INCREM 231 NUR INCR/NURSERY 232 NUR INCR/OB 233 NUR INCR/ICU 234 NUR INCR/CCU 235 NUR INCR/HOSPICE 239 NUR INCR/OTHER 249 ALL INCL ANCIL/OTHER 250 PHARMACY 251 DRUGS/GENERIC 252 DRUGS/NONGENERIC 253 DRUGS/TAKEHOME 254 DRUGS/INCIDENT ODX 255 DRUGS/INCIDENT RAD 256 DRUGS/EXPERIMT 257 DRUGS/NONPSCRPT 258 IV SOLUTIONS 259 DRUGS/OTHER 260 IV THERAPY 261 IV THER/INFSN PUMP 262 IV THER/PHARM/SVC

Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan 263 IV THER/DRUG/SUPPLY DELV 264 IV THER/SUPPLIES 269 IV THERAPY/OTHER 270 MED-SURG SUPPLIES 271 NONSTER SUPPLY 272 STERILE SUPPLY 273 TAKEHOME SUPPLY 274 PROSTH/ORTH DEV 275 PACE MAKER 276 INTR OC LENS 277 O2/TAKEHOME 278 SUPPLY/IMPLANTS 279 SUPPLY/OTHER 280 ONCOLOGY 289 ONCOLOGY/OTHER 290 MED EQUIP/DURAB 291 MED EQUIP/RENT 292 MED EQUIP/NEW 293 MED EQUIP/USED 294 MED EQUIP/SUPPLIES/DRUGS 299 MED EQUIP/OTHER 300 LABORATORY 301 LAB/CHEMISTRY 302 LAB/IMMUNOLOGY 303 LAB/RENAL HOME 304 LAB/NR DIALYSIS

Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan 305 LAB/HEMATOLOGY 306 LAB/BACT-MICRO 307 LAB/UROLOGY 309 LAB/OTHER 310 PATHOLOGY LAB 311 PATHOL/CYTOLOGY 312 PATHOL/HYSTOL 314 PATHOL/BIOPSY 319 PATHOL/OTHER 320 DX X-RAY 321 DX X-RAY/ANGIO 322 DX X-RAY/ARTH 323 DX X-RAY/ARTER 324 DX X-RAY/CHEST 329 DX X-RAY/OTHER 330 RX X-RAY 331 CHEMOTHER/INJ 332 CHEMOTHER/ORAL 333 RADIATION RX 335 CHEMOTHERP-IV 339 RX X-RAY/OTHER 340 NUCLEAR MEDICINE 341 NUC MED/DX 342 NUC MED/RX 343 Diagnostic rediopharmaceuticals 344 THERAPEUTIC PHARMACEUTICALS

Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan 349 NUC MED/OTHER 350 CT SCAN 351 CT SCAN/HEAD 352 CT SCAN/BODY 359 CT SCAN/OTHER 360 OR SERVICES 361 OR/MINOR 362 OR/ORGAN TRANS 367 OR/KIDNEY TRANS 369 OR/OTHER 370 ANESTHESIA 371 ANESTHE/INCIDENT RAD 372 ANESTHE/INCIDENT ODX 374 ANESTHE/ACUPUNC 379 ANESTHE/OTHER 380 BLOOD 381 BLOOD/PKD RED 382 BLOOD/WHOLE 383 BLOOD/PLASMA 384 BLOOD/PALTELETES 385 BLOOD/LEUCOCYTES 386 BLOOD/COMPONENTS 387 BLOOD/DERIVATIVES 389 BLOOD/OTHER 390 BLOOD/STOR-PROC 391 BLOOD/ADMIN

Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan 399 BLOOD/OTHER STOR 400 IMAGE SERVICE 401 MAMMOGRAPHY 402 ULTRASOUND 403 SCR MAMMOGRAPHY/GEN MAMMO 404 PET SCAN 409 OTHER IMAG SVS 410 RESPIRATORY SVC 412 INHALATION SVC 413 HYPERBARIC 02 419 OTHER RESPIR SVS 420 PHYSICAL THERP 421 PHYS THERP/VISIT 422 PHYS THERP/HOUR 423 PHYS THERP/GROUP 424 PHYS THERP/EVAL 429 OTHER PHYS THERP 430 OCCUPATION THER 431 OCCUP THERP/VISIT 432 OCCUP THERP/HOUR 433 OCCUP THERP/GROUP 434 OCCUP THERP/EVAL 439 OTHER OCCUP THER 440 SPEECH PATHOL 441 SPEECH PATH/VISIT 442 SPEECH PATH/HOUR

Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan 443 SPEECH PATH/GROUP 444 SPEECH PATH/EVAL 449 OTHER SPEECH PAT 450 EMERG ROOM 451 ER/EMTALA 452 ER/BEYOND EMTALA 456 URGENT CARE 459 OTHER EMER ROOM 460 PULMONARY FUNC 469 OTHER PULMON FUNC 470 AUDIOLOGY 471 AUDIOLOGY/DX 472 AUDIOLOGY/RX 479 OTHER AUDIOL 480 CARDIOLOGY 481 CARDIAC CATH LAB 482 STRESS TEST 483 ECHOCARDIOLOGY 489 OTHER CARDIOL 490 AMBUL SURG 499 OTHER AMBL SURG 500 OUTPATIENT SVS 509 OUTPATIENT/OTHER 510 CLINIC 511 CHRONIC PAIN CL 512 DENTAL CLINIC

Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan 513 PSYCH CLINIC 514 OB-GYN CLINIC 515 PEDS CLINIC 516 URGENT CLINIC 517 FAMILY CLINIC 519 OTHER CLINIC 520 FREESTAND CLINIC 521 RURAL/CLINIC 522 RURAL/HOME 523 FR/STD FAMILY CLINIC 526 FR/STD URGENT CLINIC 529 OTHER FR/STD CLINIC 530 OSTEOPATH SVS 531 OSTEOPATH RX 539 OTHER OSTEOPATH 540 AMBULANCE 541 Supplies 542 Medical Transport 544 AMBUL/OXY 545 AIR AMBULANCE 546 AMBUL/NEO-NATAL 547 AMBUL/PHARMACY 548 AMBUL/TELEPHONE EKG 549 OTHER AMBULANCE 550 SKILLED NURSING 551 SKILLED NURS/VISIT

Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan 552 SKILLED NURS/HOUR 559 SKILLED NURS/OTHER 560 MED SOCIAL SVS 561 MED SOC SERV/VISIT 562 MED SOC SERV/HOUR 569 MED SOC SERV/OTHER 570 AIDE/HOME HEALTH 571 AIDE/HOME HLTH/VISIT 572 AIDE/HOME HLTH/HOUR 579 AIDE/HOME HLTH/OTHER 580 VISIT/HOME HEALTH 581 VISIT/HOME HLTH/VISIT 582 VISIT/HOME HLTH/HOUR 589 VISIT/HOME HLTH/OTHER 590 UNIT/HOME HEALTH 599 UNIT/HOME HLTH/OTHER 600 02/HOME HEALTH 601 02/EQUIP/SUPPL/CONT 602 02/STAT EQUIP/UNDER 1 LPM 603 02/STAT EQUIP/OVER 4 LPM 604 02/STAT EQUIP/PORT ADD-ON 610 MRI 611 MRI - BRAIN 612 MRI - SPINE 614 MRI - OTHER 615 MRA - HEAD AND NECK

Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan 616 MRA - LOWER EXTREMITIES 619 MRI - OTHER 621 MED-SUR SUPP/INCIDNT RAD 622 MED-SUR SUPP/INCIDNT ODX 623 SURG DRESSING 624 IDE 630 DRUGS 631 DRUG/SNGLE 632 DRUG/MULT 633 DRUG/RSTR 634 DRUG/EPO/<=10,000 UNITS 635 DRUG/EPO/>=10,000 UNITS 636 DRUGS/DETAIL CODE 637 DRUGS/SELFADMIN 640 IV THERAPY SVC 641 NON RT NURSING/CENTRAL 642 IV SITE CARE/CENTRAL 643 IV STRT/CHNG/PERIPHAL 644 NONRT NURSING/PERIPHRL 645 TRNG/PT/CARGVR/CENTRAL 646 TRNG DSBLPT/CENTRAL 647 TRNG/PT/CARGVR/PERIPHRL 648 TRNG/DSBLPAT/PERIPHRL 649 OTHER IV THERAPY SVC 650 HOSPICE 65091 EVISCERATION OF OCULAR CONTENTS; WITHOUT IMPLANT

Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan 65093 EVISCERATION OF OCULAR CONTENTS; WITH IMPLANT 651 HOSPICE/RTN HOME 65101 65103 65105 65110 65112 65114 65125 65130 65135 65140 65150 65155 ENUCLEATION OF EYE; WITHOUT IMPLANT ENUCLEAT EYE; W/IMPLANT MUSC NOT ATTCH IMPLANT ENUCLEATION EYE; W/IMPLANT MUSCLES ATTCH IMPLANT EXENTERATION ORBIT REMOVAL ORB CONTENTS; ONLY EXENTERATION ORBITAL CONTENTS; W/REMOV BONE EXENTERAT ORBITAL CONTENTS; W/MUSC/MYOCUT FLAP MODIFICATION OCULR IMPLANT W/PLCMT/REPLCMT PEGS INSRT OCULAR IMPLNT SECNDRY; AFTER EVISCERATION INSRT OCULAR IMPLNT SECNDRY; AFTER ENUCLEATION INSRT OCULAR IMPLNT; ENUCLEAT- MUSC ATTACH-IMPLT REINSERTION OCULAR IMPLANT; W/WO CONJUNCT GRAFT REINSRT OCULAR IMPLNT; W/FOREIGN MAT REINFORCE 65175 REMOVAL OF OCULAR IMPLANT 652 HOSPICE/CTNS HOME 65205 65210 65220 65222 65235 65260 65265 65270 65272 65273 REMOVAL FB EXTERNAL EYE; CONJUNCT SUPERFICIAL REMV FB EXT EYE; CONJUNC EMBEDDED/SUBCONJUNC REMOVAL FB EXTERNAL EYE; CORNEAL W/O SLIT LAMP REMOVAL FB EXTERNAL EYE; CORNEAL W/SLIT LAMP REMOVAL FB INTRAOCULAR; FROM ANT CHAMB EYE/LENS REMV FB IO; POST SEGMT-MAGNETIC EXTRACTION REMV FB INTRAOCULR; POST SEG NONMAGNETIC XTRAC REPR LACERAT; CONJUNC W/WO LACERAT SCLERA REPR LAC; CONJUNCT MOBILIZ&REARNGMENT W/O HOSP REPR LAC; CONJUNCT MOBILIZ&REARNGMENT W/HOSP

Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan 65275 65280 65285 65286 65290 65400 REPR LAC; CORN NONPERFORATING W/WO REMOVAL FB REPR LACERAT; CORNEA PERFORATING WO UVEAL TISS REPR LACERAT; CORNEA W/REPOSIT/RESECT UVEAL TISS REPR LAC; APPLIC TISS GLUE WNDS CORN &OR SCLERA REPR WOUND XTRAOCULR MUSC TENDON &OR TENONS CAP EXCISION OF LESION CORNEA EXCEPT PTERYGIUM 65410 BIOPSY OF CORNEA 65420 65426 65430 65435 65436 65450 EXCISION/TRANSPOSITION PTERYGIUM; WITHOUT GRAFT EXCISION OR TRANSPOSITION OF PTERYGIUM; W/GRAFT SCRAPING OF CORNEA DIAGNOSTIC SMEAR &OR CULTURE REMOVAL CORNEAL EPITHELIUM; W/WO CHEMOCAUT REMOVAL CORNEAL EPITHEL; W/APPLIC CHELATING AGT DESTRUC LES CORN CRYOTHAPY PHOTOCOAG/THERMOCAUT 655 HOSPICE/IP RESPITE 656 HOSPICE/IP NON RESPITE 65600 MULTIPLE PUNCTURES OF ANTERIOR CORNEA 657 HOSPICE/PHYSICIAN 65710 KERATOPLASTY; LAMELLAR 65730 65750 65755 KERATOPLASTY; PENETRATING EXCEPT IN APHAKIA KERATOPLASTY; PENETRATING IN APHAKIA KERATOPLASTY; PENETRATING IN PSEUDOPHAKIA 65756 KERATOPLASTY ENDOTHELIAL 65757 BACKBENCH PREPJ CORNEAL ENDOTHELIAL ALLOGRAFT 65760 KERATOMILEUSIS 65765 KERATOPHAKIA 65767 EPIKERATOPLASTY

Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan 65770 KERATOPROSTHESIS 65771 RADIAL KERATOTOMY 65772 65775 65778 65779 65780 65781 65782 658 65800 65805 65810 65815 CORNL RELAXING INCI CORR SURGLY INDUCD ASTIGMA CORNL WEDGE RESECTION CORR SURGLY INDUCD ASTIGMA PLACE AMNIOTIC MEMB OCULAR SURFACE SELF RETAIN PLACE AMNIOTIC MEMBRANE OCULAR SURFACE SUTURED OCULR SURFCE RECNSTR; AMNIOTIC MEMBRANE TPLNT OCULR SURFCE RECNSTR; LIMBAL STEM CELL ALLOGFT OCULR SURFCE RECNSTR; LIMBAL CONJUNCT AUTOGFT HOSPICE ROOM AND BOARD - NURSING FACILITY PARACEN ANT CHAMB EYE-SEP PROC; W/DX ASPIR AQUES PARACEN ANT CHAMB EYE-SEP PROC; W/TX RLSE AQUEOS PARACEN ANT CHAMB EYE-SEP PROC; W/REMV VITREOUS PARACENTESIS ANT CHAMB EYE-SEP PROC; W/REMV BLD 65820 GONIOTOMY 65850 TRABECULOTOMY AB EXTERNO 65855 65860 65865 65870 65875 65880 TRABECULOPLASTY LASER SURGERY 1 OR MORE SESSIONS SEVERING ADHES ANTERIOR SEGMENT LASER TECHNIQUE SEVERING ADHESIONS-SEP PROC; GONIOSYNECHIAE SEVERING ADHESIONS-SEP PROC; ANT SYNECHIAE SEVERING ADHESIONS-SEP PROC; POST SYNECHIAE SEVERING ADHESIONS-SEP PROC; CORNEOVITREAL 659 HOSPICE/OTHER 65900 65920 65930 REMOVAL EPITHELIAL DOWNGROWTH ANT CHAMBER EYE REMOVAL IMPLANTED MATERIAL ANTERIOR SEGMENT EYE REMOVAL OF BLOOD CLOT ANTERIOR SEGMENT OF EYE Laser Scanning_KS 4 365 DAYS

Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan 660 RESPITE CARE 66020 66030 INJ ANTERIOR CHAMBER OF EYE SEP PROC; AIR/LIQUID INJECTION ANTERIOR CHAMBER OF EYE SEP PROC; MED 661 RESPITE/SKILLED NURSE 66130 EXCISION OF LESION SCLERA 66150 66155 66160 66165 66170 66172 66174 66175 66180 66185 FISTULIZ SCLERA GLAUC; TREPHINATION W/IRIDECTOMY FISTULIZ SCLERA GLAUC; THERMOCAUT W/IRIDECTOMY FISTULIZAT SCLERA; SCLERECTOMY W/PUNCH W/IRIDECT FISTULIZ SCLERA GLAUC; IRIDENCLEISIS/IRIDOTASIS FISTULIZAT SCLER;TRABECULECT AB EXT-NO OTHR SURG FISTULIZAT SCLERA; TRABECULECT AB EXT W/SCARRING TRLUML DILAT AQUEOUS CANAL W/O DEV/STNT TRLUML DILAT AQUEOUS CANAL W/DEV/STNT AQUEOUS SHUNT TO EXTRAOCULAR RESERVOIR REVISION AQUEOUS SHUNT TO EXTRAOCULAR RESERVOIR 662 RESPITE/HMEAID/HMEMKE 66220 66225 66250 66500 66505 66600 66605 66625 66630 REPAIR OF SCLERAL STAPHYLOMA; WITHOUT GRAFT REPAIR OF SCLERAL STAPHYLOMA; WITH GRAFT REVIS/REPR OPERATIVE WOUND ANT SEGMT IRIDOTOMY STAB INCI-SEP PROC; EXCEPT TRANSFIXION IRIDOTOMY-SEP PROC; W/TRANSFIXION AS IRIS BOMBE IRIDECT W/CORNEOSCLERAL/CORNL SECT; REMOVL LES IRIDECT W/CORNEOSCLERAL/CORNL SECTION; W/CYCLECT IRIDECT-CORNEOSCLERL/CORNL SECT; PERIPH GLAUC-SP IRIDECT-CORNEOSCLERAL/CORNL SECT;SECTOR GLAUC-SP

Kan 66635 IRIDECT W/CORNEOSCLERAL/CORNEAL SECT; OPTICAL-SP Kan 66680 REPAIR OF IRIS CILIARY BODY Kan 66682 SUTURE IRIS CILIARY BODY-SEP PROC W/RETRIEVL SUT Kan 66700 CILIARY BODY DESTRUCTION; DIATHERMY Kan 66710 CILIARY BDY DESTRUC; CYCLOPHOTOCOAG TRANSSCLERAL Kan 66711 CILIARY BODY DESTRCTION; CYCLOPHOTOCOAGULAT ENDO Kan 66720 CILIARY BODY DESTRUCTION; CRYOTHERAPY Kan 66740 CILIARY BODY DESTRUCTION; CYCLODIALYSIS Kan 66761 IRIDOTOMY/IRIDECTOMY BY LASER SURGERY Laser Scanning_KS 4 365 DAYS Kan 66762 IRIDOPLASTY BY PHOTOCOAGULATION Kan 66770 DESTRUCTION CYST OR LESION IRIS OR CILIARY BODY Kan 66820 DISCISSION SEC MEMB CATARACT; STAB INCI TECH Kan 66821 DISCISSION SEC MEMB CATARACT; LASER SURGERY Laser Scanning_KS 4 365 DAYS Kan 66825 REPSTN INTRAOCULR LENS PROSTH RQR INCI-SEP PROC Kan 66830 REMV 2ND MEMBRN CATARACT W/CORNEO-SCLERAL SECT Kan 66840 REMOVAL LENS MATL; ASPIR TECHNIQUE 1/MORE STAGES Kan 66850 REMOVL LENS MATL; PHACOFRAGATION TECH W/ASPIR Kan 66852 REMOVL LENS MATL; PARS PLANA APPRCH W/WO VITRECT Kan 66920 REMOVAL OF LENS MATERIAL; INTRACAPSULAR Kan 66930 REMOVAL LENS MATERIAL; INTRACAPSULAR DISLOC LENS Kan 66940 REMOVAL OF LENS MATERIAL; EXTRACAPSULAR Kan 66982 EXTRACAP CATARACT REMV W/IOL- COMPLX-DIFF TECH Kan 66983 INTRACAPSULAR CATARACT EXTRAC W/INSRT IOL PROSTH Kan 66984 EXTRACAPSULAR CATARACT REMV W/INSRT IOL PROSTH Kan 66985 INSERT IOL PROSTHESIS- SECONDARY IMPLANT

Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan 66986 EXCHANGE OF INTRAOCULAR LENS 66999 UNLISTED PROCEDURE ANTERIOR SEGMENT OF EYE 670 OP SPEC RES 67005 67010 67015 67025 67027 67028 67030 67031 67036 67039 67040 67041 67042 67043 REMOVAL VITREOUS ANT APPROACH; PARTIAL REMOVAL REMV VITREOUS ANT; SUBTL REMV W/MECH VITRECT ASPIRAT/RELEASE VITREOUS/SUBRETINAL FLUID INJ VITREOUS SUBSTITUTE-W/WO ASPIRAT-SEP PROC IMPLANT INTRAVITREAL DRUG DELIVERY SYSTEM INTRAVITREAL INJECTION OF A PHARMACOLOGIC AGENT DISCISSION VITREOUS STRANDS PARS PLANA APPROACH SEVERING VITREOUS STRANDS/MEMBRN-LASER SURG VITRECTOMY MECHANICAL PARS PLANA APPROACH; VITRECTOMY MECH; W/FOCAL ENDOLASER PHOTOCOAGULAT VITRECTOMY MECH; W/ENDOLASER PANRETINAL PHOTOCOA VITRECTOMY PARS PLANA REMOVE PRERETINAL MEMBRANE VITRECTOMY PARS PLANA REMOVE INT MEMB RETINA VITRECTOMY PARS PLANA REMOVE SUBRETINAL MEMBRANE 671 OP SPEC RES/HOSP BASED 67101 67105 67107 67108 67110 67112 67113 REPR RETINAL DETACHMENT; CRYOTHERAPY/DIATHERMY REPR RETINAL DETACHMENT; PHOTOCOAGULATION REPR RETINAL DETACHMENT; SCLERAL BUCKLING REPR RETINAL DETACHMENT; W/VITRECTOMY ANY METHD REPAIR RET DETACH; INJECTION AIR/OTHER GAS REPR RETINAL DETACHMENT; PREV RET DETACH REPR RPR COMPLEX RETINA DETACH VITRECTOMY & MEMB PEEL 67115 RELEASE OF ENCIRCLING MATERIAL Laser Scanning_KS 4 365 DAYS

Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan 67120 67121 67141 67145 REMOVAL IMPL MATERIAL POST SEGMENT; XTRAOCULR REMOVAL IMPL MATERIAL POST SEGMENT; INTRAOCULR PROPHYLAXIS RETINL DETACH W/O DRAIN; CRYOTHERAPY PROPH RET DETACH W/O DRN 1/MORE SESSS; PHOTOCOAG 672 OP SPEC RES/CONTRACTED 67208 67210 67218 67220 67221 67225 67227 67228 67229 67250 67255 67299 67311 67312 67314 67316 67318 67320 67331 67332 67334 DESTRCT LOCALIZ LES RETINA; CRYOTHERAPY/DIATHERM DESTRUC LOC LES RETINA 1/MORE SESSS; PHOTOCOAG DESTRCT LOCALIZ LES RETINA; RADIATION-IMPLNT DESTRUC LOC LES CHOROID; PHOTOCOAG 1/MORE SESS DESTRUC LOC LESION CHOROID; PHOTODYNAMIC THERAPY DSTRUC LOC LES CHOROID; PHOTODYN TX 2 EYE 1 SESS DESTRCT PROGRESSIVE RETINOPATHY; CRYOTHERAPY DESTRCT PROGRESSIVE RETINOPATHY; PHOTOCOAGULAT EXTENSIVE RETINOPATHY 1+ SESS PRETERM INFANT SCLERAL REINFORCEMENT; WITHOUT GRAFT SCLERAL REINFORCEMENT; WITH GRAFT UNLISTED PROCEDURE POSTERIOR SEGMENT STRABISMUS SURGERY R/R PROC; 1 HORIZONTAL MUSCLE STRABISMUS SURGERY R/R PROC; 2 HORIZONTAL MUSC STRABISMUS SURGERY R/R PROC; 1 VERTICAL MUSCLE STRAB SURGERY R/R PROC; TWO/MORE VERTICAL MUSC STRAB SURGERY ANY PROC SUPERIOR OBLIQUE MUSCLE TRANSPOSITION PROCEDURE ANY EXTRAOCULAR MUSCLE STRABISMUS SURG-PT W/PREV EYE SURGERY/INJURY STRABISMUS SURG-PT W/SCARRING EXTRAOCULAR MUSC STRAB SURG POST FIX SUT TECH W/WO MUSC RECESSION Laser Scanning_KS 4 365 DAYS Laser Scanning_KS 4 365 DAYS Laser Scanning_KS 4 365 DAYS

Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan 67335 67340 67343 67345 PLCMT ADJUSTABLE SUTURE- DURING STRABISMUS SURG STRABISMUS SURG EXPLOR &/OR REPR DETACHED MUSC RLSE EXT SCAR TISS W/O DETACH XTRAOCULR MUSC-SP CHEMODENERVATION OF EXTRAOCULAR MUSCLE 67346 BIOPSY EXTRAOCULAR MUSCLE 67350 BIOPSY OF EXTRAOCULAR MUSCLE 67399 67400 67405 67412 67413 67414 67415 67420 67430 67440 67445 67450 67500 UNLISTED PROCEDURE OCULAR MUSCLE ORBITOTOMY WITHOUT BONE FLAP; EXPL W/WO BX ORBITOTOMY WITHOUT BONE FLAP; WITH DRAINAGE ONLY ORBITOTOMY WITHOUT BONE FLAP; W/REMOVAL LESION ORBITOTOMY WITHOUT BONE FLP; W/REMOVAL FB ORBITOT W/O BONE FLP; W/REMOVAL BONE DECOMPRS FINE NEEDLE ASPIRATION OF ORBITAL CONTENTS ORBITOT W/BN FLP/WINDOW LAT APPRCH; W/REMOVL LES ORBITOT W/BN FLP/WINDOW LAT APPRCH; W/REMOVAL FB ORBITOTOMY W/BONE FLP/WINDOW LAT APPRCH; W/DRAIN ORBITOTOMY W/BONE FLAP/WINDOW; W/REMV BONE ORBITOT W/BN FLP/WINDOW LAT APPRCH; EXPL W/WO BX RETROBULBAR INJECTION; MEDICATION 67505 RETROBULBAR INJECTION; ALCOHOL 67515 INJECTION MEDICATION/OTH SUBSTANCE IN TENONS CAP 67550 ORBITAL IMPLANT; INSERTION 67560 ORBITAL IMPLANT; REMOVAL OR REVISION 67570 OPTIC NERVE DECOMPRESSION 67599 UNLISTED PROCEDURE ORBIT

Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan 67700 BLEPHAROTOMY DRAINAGE OF ABSCESS EYELID 67710 SEVERING OF TARSORRHAPHY 67715 CANTHOTOMY 67800 EXCISION OF CHALAZION; SINGLE 67801 67805 67808 EXCISION OF CHALAZION; MULTIPLE SAME LID EXCISION OF CHALAZION; MULTIPLE DIFFERENT LIDS EXC CHALAZION; UNDER GEN ANES- &/ RQR HOSP 1/MX 67810 BIOPSY OF EYELID 67820 67825 67830 67835 67840 67850 67875 67880 67882 CORRECTION OF TRICHIASIS; EPILATION FORCEPS ONLY CORRECT TRICHIASIS; EPILATION OTH THAN FORCEPS CORRECTION OF TRICHIASIS; INCISION OF LID MARGIN CORRECT TRICHIASIS; INCS LID MARGIN W/MEMBRN GFT EXCISION LESION EYELID W/O CLOS/W/SMPL DIR CLOS DESTRUCTION OF LESION OF LID MARGIN TEMPORARY CLOSURE OF EYELIDS BY SUTURE CONSTRUCT INTERMARGINAL ADHESIONS CONSTRCT INTERMARG ADHESIONS; W/TRANSPOSIT TARSL 679 OP SPEC RES/OTHER 67900 REPAIR OF BROW PTOSIS 67901 67902 67903 67904 67906 67908 67909 RPR BLPOS FRNTIS MUSC SUTR/OTH MATRL RPR BLPOS FRNTIS MUSC AUTOL FSCAL SLING REP BLEPHAROPT; LEVATOR RES/ADVMENT INTRL APPRCH REPR BLEPHAROPT; LEVATOR RES/ADVMENT EXT APPRCH REPR BLEPHAROPT; SUP RECTUS TECH W/FASCL SLING REPR BLEPHAROPTOSIS; CONJUNC- TARSO-MULLER'S REDUCTION OF OVERCORRECTION OF PTOSIS

Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan 67911 CORRECTION OF LID RETRACTION 67912 CORR LAGOPHTHALMOS W/IMPL UPPER EYELID LID LOAD 67914 REPAIR OF ECTROPION; SUTURE 67915 67916 REPAIR OF ECTROPION; THERMOCAUTERIZATION REPAIR ECTROPION; EXCISION TARSAL WEDGE 67917 REPAIR OF ECTROPION; EXTENSIVE 67921 REPAIR OF ENTROPION; SUTURE 67922 67923 REPAIR OF ENTROPION; THERMOCAUTERIZATION REPAIR ENTROPION; EXCISION TARSAL WEDGE 67924 REPAIR OF ENTROPION; EXTENSIVE 67930 67935 67938 SUTURE RECENT WOUND EYELID DIR CLOS; PART THICK SUTURE RECENT WOUND EYELID DIR CLOS; FULL THICK REMOVAL OF EMBEDDED FOREIGN BODY EYELID 67950 CANTHOPLASTY 67961 67966 67971 67973 67974 67975 EXC & REPR EYELID; UP TO 1/4 LID MARGIN EXC & REPR EYELID > 1/4 LID MARGIN RECON EYELID FULL THICK; UP TO 2/3 LID 1 STAGE RECON EYELID; TOT LID LOWER 1 STAGE/1ST STAGE RECON EYELID; TOT LID UPPER 1 STAGE/1ST STAGE RECON EYELID FULL THICK-TRANSF FLAP; 2ND STAGE 67999 UNLISTED PROCEDURE EYELIDS 68020 68040 INCISION OF CONJUNCTIVA DRAINAGE OF CYST EXPRESSION OF CONJUNCTIVAL FOLLICLES 681 LEVEL 1 68100 BIOPSY OF CONJUNCTIVA 68110 EXCISION OF LESION CONJUNCTIVA; UP TO 1 CM

Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan 68115 68130 68135 EXCISION OF LESION CONJUNCTIVA; OVER 1 CM EXCISION LESION CONJUNCTIVA; W/ADJACENT SCLERA DESTRUCTION OF LESION CONJUNCTIVA 682 LEVEL 2 68200 SUBCONJUNCTIVAL INJECTION 683 LEVEL 3 68320 68325 68326 68328 68330 68335 68340 68360 CONJUNCTPLSTY; W/CONJUNCT GRAFT/EXT REARNGMENT CONJUNCTPLSTY; W/BUCCAL MUCOUS MEMBRANE GRAFT CONJUNCTIVOPLASTY RECON CUL- DE-SAC; W/GFT CONJUNCTIVOPLASTY RECON CUL- DE-SAC; W/BUCCAL GFT REPAIR SYMBLEPHARON; CONJUNCTPLSTY WITHOUT GRAFT REPR SYMBLEPHARON; W/FREE GFT CONJUNC/BUCCAL REPR SYMBLEPHARON; DIVIS SYMBLEPHARON W/WO INSRT CONJUNCTIVAL FLAP; BRIDGE OR PARTIAL 68362 CONJUNCTIVAL FLAP; TOTAL 68371 68399 HARVESTING CONJUNCTIVAL ALLOGRAFT LIVING DONOR UNLISTED PROCEDURE CONJUNCTIVA 684 LEVEL 4 68400 68420 68440 68500 68505 INCISION DRAINAGE OF LACRIMAL GLAND INCISION DRAINAGE OF LACRIMAL SAC SNIP INCISION OF LACRIMAL PUNCTUM EXCISION OF LACRIMAL GLAND EXCEPT TUMOR; TOTAL EXCISION OF LACRIMAL GLAND EXCEPT TUMOR; PARTIAL 68510 BIOPSY OF LACRIMAL GLAND 68520 EXCISION OF LACRIMAL SAC 68525 BIOPSY OF LACRIMAL SAC

Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan 68530 68540 68550 REMOVAL FB/DACRYOLITH LACRIMAL PASSAGES EXCISION LACRIMAL GLAND TUMOR; FRONTAL APPROACH EXCISION LACRIMAL GLAND TUMOR; INVLV OSTEOTOMY 68700 PLASTIC REPAIR OF CANALICULI 68705 CORRECTION OF EVERTED PUNCTUM CAUTERY 68720 DACRYOCYSTORHINOSTOMY 68745 68750 68760 68761 CONJUNCTIVORHINOSTOMY; WITHOUT TUBE CONJUNCTIVORHINOSTOMY; W/INSERTION TUBE OR STENT CLOS LAC PUNCTUM; THERMOCAUT LIG/LASER SURGERY CLOSURE OF THE LACRIMAL PUNCTUM; BY PLUG EACH 68770 CLOSURE OF LACRIMAL FISTULA 68801 68810 68811 68815 68816 68840 68850 68899 DILATION OF LACRIMAL PUNCTUM W/WO IRRIGATION PROBING OF NLD WITH OR WITHOUT IRRIGATION; PROBING NLD W/WO IRRIGATION; RQR GEN ANESTHESIA PROBING NLD W/WO IRRIG; W/INSRTION TUBE/STENT PROBE NASOLACRIMAL DUCT WITH CATHETER DILATION PROBING OF LACRIMAL CANALICULI W/WO IRRIGATION INJECTION OF CONTRAST MEDIUM DACRYOCYSTOGRAPHY UNLISTED PROCEDURE LACRIMAL SYSTEM 689 OTHER TRAUMA RESPONSE 700 CAST ROOM 709 OTHER CAST ROOM 710 RECOVERY ROOM 719 OTHER RECOV RM 720 DELIVROOM/LABOR 721 LABOR

Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan 722 DELIVERY ROOM 723 CIRCUMCISION 724 BIRTHING CENTER 729 OTHER/DELIV-LABOR 730 EKG/ECG 731 HOLTER MONT 732 TELEMETRY 739 OTHER EKG-ECG 740 EEG 749 OTHER EEG 750 GASTR-INTS SVS 759 OTHER GASTRO-INTS 760 TREATMENT/OBSERVATION RM 761 TREATMENT RM 762 OBSERVATION RM 76510 76511 76512 76513 76514 76516 76519 76529 OPHTHALMIC US DX; B-SCAN&QUAN A-SCAN SAME ENCNTR OPHTHALMIC US DX; QUANTITATIVE A-SCAN ONLY OPHTHALMIC US DX; B-SCAN W/WO NON-QUAN A-SCAN OPHTHALMIC US DX; ANT SEG US B- SCAN/BIOMICROSCPY OPHTHALMIC US DX; CORNEAL PACHYMETRY UNI/BIL OPHTHALMIC BIOMETRY ULTRASOUND ECHO A-SCAN; OPHTH BIOMETRY A-SCAN; W/IO LENS POWER CALCULAT OPHTHALMIC ULTRASONIC FOREIGN BODY LOCALIZATION 769 OTHER TREATMENT RM 770 PREVENT CARE SVS 771 VACCINE ADMIN

Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan 779 OTHER PREVENT 780 TELEMEDICINE 789 TELEMEDICINE/OTHER 790 LITHOTRIPSY 799 LITHOTRIPSY/OTHER 800 RENAL DIALYSIS 801 DIALY/INPT 802 DIALY/INPT/PER 803 DIALY/INPT/CAPD 804 DIALY/INPT/CCPD 809 DIALY/INPT/OTHER 810 ORGAN ACQUISIT 811 LIVING/DONOR 812 CADAVER/DONOR 813 UNKNOWN/DONOR 814 UNSUCCESSFUL SEARCH 819 OTHER/DONOR 820 HEMO/OP OR HOME 821 HEMO/COMPOSITE 822 HEMO/HOME/SUPPL 823 HEMO/HOME/EQUIP 824 HEMO/HOME/100% 825 HEMO/HOME/SUPSERV 829 HEMO/HOME/OTHER 830 PERITONEAL/OP OR HOME 831 PERTNL/COMPOSITE

Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan 832 PERTNL/HOME/SUPPL 833 PERTNL/HOME/EQUIP 834 PERTNL/HOME/100% 835 PERTNL/HOME/SUPSERV 839 PERTNL/HOME/OTHER 840 CAPD/OP OR HOME 841 CAPD/COMPOSITE 842 CAPD/HOME/SUPPL 843 CAPD/HOME/EQUIP 844 CAPD/HOME/100% 845 CAPD/HOME/SUPSERV 849 CAPD/HOME/OTHER 850 CCPD/OP OR HOME 851 CCPD/COMPOSITE 852 CCPD/HOME/SUPPL 853 CCPD/HOME/EQUIP 854 CCPD/HOME/100% 855 CCPD/HOME/SUPSERV 859 CCPD/HOME/OTHER 880 DIALY/MISC 881 DIALY/ULTRAFILT 882 HOME DIALYSIS AID VISIT 889 DIALY/MISC/OTHER 900 PSTAY TREATMENT 901 ELECTRO SHOCK 902 MILIEU THERAPY

Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan 903 PLAY THERAPY 904 ACTIVITY THERAPY 905 906 Intensive outpatient servicespsychiatric INTENSIVE OUTPATIENT SERVICES- CHEMICAL DEPENDENCY 909 OTHER PSTAY RX 910 PSYCH/SERVICES 911 PSYCH/REHAB 912 PSYCH/PARTIAL HOSP 913 PSYCH/PARTIAL INSTENSIVE 914 PSYCH/INDIV RX 915 PSYCH/GROUP RX 916 PSYCH/FAMILY RX 917 PSYCH/BIOFEED 918 PSYCH/TESTING 919 PSYCH/OTHER 920 OTHER DX SVS 92002 92002 92002 92002 92004 92004 92004 92004 92012 92012 OPHTH SERV: MED EXAM & EVAL; INTERMED NEW PT OPHTH SERV: MED EXAM & EVAL; INTERMED NEW PT OPHTH SERV: MED EXAM & EVAL; INTERMED NEW PT OPHTH SERV: MED EXAM & EVAL; INTERMED NEW PT OPHTH SERV: MED EXAM; COMP NEW PT 1/MORE VISITS OPHTH SERV: MED EXAM; COMP NEW PT 1/MORE VISITS OPHTH SERV: MED EXAM; COMP NEW PT 1/MORE VISITS OPHTH SERV: MED EXAM; COMP NEW PT 1/MORE VISITS OPHTH SERV: MED EXAM & EVAL; INITERMED ESTAB PT OPHTH SERV: MED EXAM & EVAL; INITERMED ESTAB PT Exam Ophthalmology_KS Exam Ophthalmology_KS Exam_Vision_KS Exam_Vision_KS Exam Ophthalmology_KS Exam Ophthalmology_KS Exam_Vision_KS Exam_Vision_KS Exam Ophthalmology_KS Exam Ophthalmology_KS

Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan 92012 92012 92014 92014 92014 92014 92015 92015 92018 OPHTH SERV: MED EXAM & EVAL; INITERMED ESTAB PT OPHTH SERV: MED EXAM & EVAL; INITERMED ESTAB PT OPHTH SERV: MED EXAM & EVAL; COMP ESTAB PT OPHTH SERV: MED EXAM & EVAL; COMP ESTAB PT OPHTH SERV: MED EXAM & EVAL; COMP ESTAB PT OPHTH SERV: MED EXAM & EVAL; COMP ESTAB PT DETERMINATION OF REFRACTIVE STATE DETERMINATION OF REFRACTIVE STATE OPHTH EXAM & EVAL-GEN ANES; CMPL 92019 OPHTH EXAM & EVAL-GEN ANES; LTD 92020 GONIOSCOPY 92020 GONIOSCOPY 92025 92060 92065 92070 92071 92081 92081 92081 92082 92082 92082 92083 92083 92083 COMPUTERIZED CORNEAL TOPOGRAPHY UNI/BI SENSIMOTOR EXAM W/MX MSR OCULR DEV W/I&R-SP ORTHOPTIC &/ PLEOPTIC TRAIN W/MED DIRECT & EVAL FIT CNTC LENS TX DISEASE INCLUDING SUPPLY LENS FIT CONTACT LENS TX OCULAR SURFACE DISEASE VISUAL FIELD EXAM UNI/BIL W/I&R; LTD EXAM VISUAL FIELD EXAM UNI/BIL W/I&R; LTD EXAM VISUAL FIELD EXAM UNI/BIL W/I&R; LTD EXAM VISUAL FIELD EXAM UNI/BIL W/I&R; INTERMED VISUAL FIELD EXAM UNI/BIL W/I&R; INTERMED VISUAL FIELD EXAM UNI/BIL W/I&R; INTERMED VISUAL FIELD EXAM UNI/BIL W/I&R; EXTENDED EXAM VISUAL FIELD EXAM UNI/BIL W/I&R; EXTENDED EXAM VISUAL FIELD EXAM UNI/BIL W/I&R; EXTENDED EXAM Exam_Vision_KS Exam_Vision_KS Exam Ophthalmology_KS Exam Ophthalmology_KS Exam_Vision_KS Exam_Vision_KS Refraction_KS Refraction_KS Exam_Vision_KS Exam_Vision_KS Corneal Topography_KS Visual Field Examination_KS 4 365 DAYS Exam_Vision_KS Exam_Vision_KS Visual Field Examination_KS 4 365 DAYS Exam_Vision_KS Exam_Vision_KS Visual Field Examination_KS 4 365 DAYS Exam_Vision_KS Exam_Vision_KS

Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan 921 PERI VASCUL LAB 92100 92100 92120 92130 92132 92132 92133 92133 92134 92134 92135 92136 92140 92140 SERIAL TONOMETRY-SEP PROC W/I&R SAME DAY SERIAL TONOMETRY-SEP PROC W/I&R SAME DAY TONOGRAPHY W/I&R-RECORD INDENTAT TONOMETER TONOGRAPHY WITH WATER PROVOCATION CMPTR OPHTHALMIC DX IMG ANT SEGMT W/I&R UNI/BI CMPTR OPHTHALMIC DX IMG ANT SEGMT W/I&R UNI/BI COMPUTERIZED OPHTHALMIC IMAGING OPTIC NERVE COMPUTERIZED OPHTHALMIC IMAGING OPTIC NERVE COMPUTERIZED OPHTHALMIC IMAGING RETINA COMPUTERIZED OPHTHALMIC IMAGING RETINA SCANNING CMPTIZED OPHTH DX IMAGING W/I&R UNI OPHTH BIOMETRY PART COHERENCE INTRFEROMETRY PROVOCATIVE TESTS GLAUC W/I&R WITHOUT TONOGRAPHY PROVOCATIVE TESTS GLAUC W/I&R WITHOUT TONOGRAPHY 922 EMG 92225 92226 92227 92228 OPHTHALMOSCOPY EXT W/RETINAL DRAWING W/I&R; INIT OPHTH EXT W/RETINAL DRAWING W/I&R; SUBSEQUENT REMOTE IMG DX RETINL DIS W/ALYS & REPORT UNI/BI REMOTE IMG MGT RETINL DIS W/I&R UNI/BI 92230 FLUORESCEIN ANGIOSCOPY W/I&R 92235 FLUORESCEIN ANGIOGRAPHY W/I&R 92240 INDOCYANINE-GREEN ANGIOGRAPHY W/I&R 92250 FUNDUS PHOTOGRAPHY W/I&R 92260 OPHTHALMODYNAMOMETRY Exam_Vision_KS Exam_Vision_KS Exam_Vision_KS Exam_Vision_KS Exam_Vision_KS Exam_Vision_KS Exam_Vision_KS Exam_Vision_KS Exam_Vision_KS Exam_Vision_KS

Kan 92265 NEEDLE OCULOELECTROMYOGRAPHY 1/MORE MUSCL W/I&R Kan 92270 ELECTRO-OCULOGRAPHY W/I&R Kan 92275 ELECTRORETINOGRAPHY W/I&R Kan 92283 COLOR VISION EXAM EXT EG ANOMALOSCOPE/EQUIVALENT Kan 92284 DARK ADAPTATION EXAMINATION W/I&R Kan 92285 EXT OCULR PHOTOGRAPHY W/I&R DOC MEDICAL PROGRESS Kan 92286 SPEC ANT SEGMT PHOTO W/I&R; W/MICRO/CELL CNT Kan 92287 SPCL ANT SEG PHOTGRPH W/I&R; W/FLUORESCEIN ANGIO Kan 923 PAP SMEAR Kan 92310 PRSC & FIT CONTACT LENS; CORNEAL EXCEPT APHAKIA Fitting_Ophthalmology_KS Kan 92311 PRSC & FIT CONTACT LENS; CORNEAL-APHAKIA-1EYE Fitting_Ophthalmology_KS Kan 92312 PRSC CONTACT LENS; CORNEAL- APHAKIA-BOTH EYES Fitting_Ophthalmology_KS Kan 92313 PRSC & FIT CONTACT LENS; CORNEOSCLERAL LENS Fitting_Ophthalmology_KS Kan 92316 PRSC W/FIT BY TECH; LENS- APHAKIA-BOTH EYES Kan 92317 PRSC W/FIT BY TECH; CORNEOSCLERAL LENS Kan 92325 MODIFICATION CNTC LENS W/MEDICAL SUPERVIS ADPT Kan 92326 REPLACEMENT OF CONTACT LENS Kan 92340 FITTING OF SPECTACLES EXCEPT APHAKIA; MONOFOCAL Fitting_Ophthalmology_KS Kan 92340 FITTING OF SPECTACLES EXCEPT APHAKIA; MONOFOCAL Fitting_Vision_KS Kan 92341 FITTING OF SPECTACLES EXCEPT APHAKIA; BIFOCAL Fitting_Ophthalmology_KS Kan 92341 FITTING OF SPECTACLES EXCEPT APHAKIA; BIFOCAL Fitting_Vision_KS Kan 92342 FIT SPECTACLES EX APHAKIA; MULTIFOCAL NOT BIFOCL Fitting_Ophthalmology_KS Kan 92342 FIT SPECTACLES EX APHAKIA; MULTIFOCAL NOT BIFOCL Fitting_Vision_KS Kan 92352 FITTING SPECTACLE PROSTHESIS APHAKIA; MONOFOCAL Fitting_Ophthalmology_KS Kan 92352 FITTING SPECTACLE PROSTHESIS APHAKIA; MONOFOCAL Fitting_Vision_KS

Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan 92353 92353 92354 92354 92355 92355 92370 92370 92371 FITTING SPECTACLE PROSTHESIS APHAKIA; MULTIFOCAL FITTING SPECTACLE PROSTHESIS APHAKIA; MULTIFOCAL FIT SPECTACLE MOUNTED LOW VISION AID; 1 ELEM SYS FIT SPECTACLE MOUNTED LOW VISION AID; 1 ELEM SYS FIT SPECTACL MOUNT LO VISION AID; TELESCOP/OTHER FIT SPECTACL MOUNT LO VISION AID; TELESCOP/OTHER REPAIR AND REFITTING SPECTACLES; EXCEPT APHAKIA REPAIR AND REFITTING SPECTACLES; EXCEPT APHAKIA REPR&REFIT SPECTACLES; SPECTACLE PROSTH APHAKIA 924 ALLERGY TEST 925 PREG TEST 929 ADDITIONAL DX SVS 940 OTHER RX SVS 941 RECREATION RX 942 EDUC/TRAINING 943 CARDIAC REHAB 944 DRUG REHAB 945 ALCOHOL REHAB 946 RTN COMPLX MED EQUIP 947 COMPLX MED EQUIP 949 ADDITIONAL RX SVS 951 ATHLETIC TRAINING 95930 VISL EVOKED PTNTL TST CNTRL NRV SYS CHKRBD/FLASH 960 PRO FEE 961 PRO FEE/PSTAY 962 PRO FEE/EYE Fitting_Ophthalmology_KS Fitting_Vision_KS Fitting_Ophthalmology_KS Fitting_Vision_KS Fitting_Ophthalmology_KS Fitting_Vision_KS

Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan 963 PRO FEE/ANES MD 964 PRO FEE/ANES CRNA 969 OTHER PRO FEE 971 PRO FEE/LAB 972 PRO FEE/RAD/DX 973 PRO FEE/RAD/RX 974 PRO FEE/NUC MED 975 PRO FEE/OR 976 PRO FEE/RESPIR 977 PRO FEE/PHYSI 978 PRO FEE/OCUPA 979 PRO FEE/SPEECH 981 PRO FEE/ER 982 PRO FEE/OUTPT 983 PRO FEE/CLINIC 984 PRO FEE/SOC SVC 985 PRO FEE/EKG 986 PRO FEE/EEG 987 PRO FEE/HOS VIS 988 PRO FEE/CONSULT 989 FEE/PVT NURSE 990 PT CONVENIENCE 991 CAFETERIA 99173 99173 SCREENING TEST VISUAL ACUITY QUANTITATIVE BIL SCREENING TEST VISUAL ACUITY QUANTITATIVE BIL 992 LINEN Exam Ophthalmology_KS Exam Ophthalmology_KS

Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan 99201 OFFICE OUTPT NEW 10 MIN 99202 OFFICE OUTPT NEW 20 MINUTES 99203 OFFICE OUTPT NEW 30 MIN 99204 OFFICE OUTPT NEW 45 MIN 99205 OFFICE OUTPT NEW 60 MIN 99211 99212 99213 99214 99215 99217 99218 99219 99220 OFC/OUTPT VISIT E&M ESTAB NO PHYS PRES 5 MIN OFC/OUTPT VISIT E&M EST SELF- LIMIT/MINOR 10 MIN OFC/OUTPT VISIT E&M EST LOW- MOD SEVERITY 15 MIN OFC/OUTPT VISIT E&M EST MOD-HI SEVERITY 25 MIN OFC/OUTPT VISIT E&M ESTAB MOD- HI SEVRTY 40 MIN OBSERVATION CARE DISCHARGE DAY MANAGEMENT INIT OBSRV CARE-DAY E&M LOW SEVERITY INIT OBSRV CARE-DAY E&M MODERATE SEVERITY INIT OBSRV CARE-DAY E&M HIGH SEVERITY 99221 1ST HOSP CARE PR D 30 MIN 99222 99223 99224 99225 99226 99231 99232 99233 99234 99235 99236 INIT HOSP CARE-DAY E&M MODERATE SEVERITY 50 MIN INIT HOSP CARE-DAY E&M HIGH SEVERITY 70 MIN SBSQ OBS CARE PR D LOW SEVERITY SBSQ OBS CARE PR D MODERATE SEVERITY SBSQ OBS CARE PR D HIGH SEVERITY SUBSQT HOSP CARE-DAY E&M STABLE/RECOVER 15 MIN SUBSQT HOSP CARE-DAY E&M MINOR CMPL 25 MIN SUBSQT HOSP CARE-DAY E&M SIGNIFIC CMPL 35 MIN OBSRV/INPT HOSP CARE E&M LOW SEVERITY OBSRV/INPT HOSP CARE E&M MODERATE SEVERITY OBSRV/INPT HOSP CARE E&M HIGH SEVERITY

Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan 99238 99239 99241 99242 99243 99244 99245 99251 99252 99253 HOSPITAL D/C DAY MANAGEMENT; 30 MINUTES/LESS HOSPITAL DISCHARGE DAY MANAGEMENT; > 30 MINUTES OFFICE CNSLT NEW/ESTAB SELF LIMIT/MINOR 15 MIN OFFICE CNSLT NEW/ESTAB LOW SEVERITY 30 MIN OFFICE CNSLT NEW/ESTAB MODERATE SEVERITY 40 MIN OFFICE CNSLT NEW/ESTAB MOD- HIGH SEVERITY 60 MIN OFFICE CNSLT NEW/ESTAB MOD- HIGH SEVERITY 80 MIN INIT INPT CNSLT NEW/EST SELF LIMIT/MINOR 20 MIN INIT INPT CNSLT NEW/ESTAB LOW SEVERITY 40 MIN INIT INPT CNSLT NEW/EST MODERATE SEVERITY 55MIN 99254 1ST INPT CONSLTJ 80 MIN 99255 99281 99282 99283 99284 99285 INIT INPT CNSLT NEW/EST MOD-HI SEVERITY 110 MIN EMERG DEPT VISIT E&M SELF LIMITED/MINOR EMERG DEPT VISIT E&M LOW- MODERATE SEVERITY EMERG DEPT VISIT E&M MODERATE SEVERITY EMERG DEPT VISIT E&M HIGH SEVERITY URGENT EVAL EMERG DEPT E&M-HIGH SEVERITY IMMED SIG THREAT 993 TELEPHONE 994 TV/RADIO 995 NONPT ROOM RENT 996 LATE DISCHARGE 997 ADMIT KITS 998 BARBER/BEAUTY 999 PT CONVENCE/OTH J0585 BOTULINUM TOXIN TYPE A PER UNIT J2503 INJECTION PEGAPTANIB SODIUM 0.3 MG 800 1 DAYS 4 1 DAYS

Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan J2778 INJECTION RANIBIZUMAB 0.1 MG J3300 J3301 INJ TRIAMCINOLONE ACETONIDE PRES FREE 1 MG INJECTION TRIAMCINOLONE ACETONIDE PER 10 MG J3396 INJECTION VERTEPORFIN 0.1 MG J7312 INJECTION DEXAMETHASONE INTRAVITREAL IMPL 0.1 MG J9035 INJECTION BEVACIZUMAB 10 MG L8610 OCULAR IMPLANT L8612 AQUEOUS SHUNT Q2046 INJECTION AFLIBERCEPT 1 MG S0500 DISPOSABLE CONTACT LENS PER LENS S0580 POLYCARBONATE LENS S0580 POLYCARBONATE LENS S0620 ROUTINE OPHTH EXAM INCL REFRACTION; NEW PT V2020 FRAMES PURCHASES V2020 FRAMES PURCHASES V2025 DELUXE FRAME V2100 V2101 V2101 V2102 V2102 V2103 V2103 V2104 V2104 V2105 SPHERE SINGLE VISION PLANO +/- 4.00 PER LENS SPHERE SINGLE VISION +/- 4.12 +/- 7.00D PER LENS SPHERE SINGLE VISION +/- 4.12 +/- 7.00D PER LENS SPHERE SINGLE VISN +/- 7.12 +/- 20.00D PER LENS SPHERE SINGLE VISN +/- 7.12 +/- 20.00D PER LENS 1 VISN PLANO TO+/-4.00D SPHER 0.12-2.00D CYL EA 1 VISN PLANO TO+/-4.00D SPHER 0.12-2.00D CYL EA 1 VISN PLANO-+/- 4.00D SPHER 2.12-4.00D CYL EA 1 VISN PLANO-+/- 4.00D SPHER 2.12-4.00D CYL EA 1 VISN PLANO-+/- 4.00D SPHER 4.25-6.00D CYL EA 10 1 DAYS 240 1 DAYS 16 1 DAYS 300 1 DAYS 14 1 DAYS 400 1 DAYS 4 1 DAYS

Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan V2105 V2106 V2106 V2107 V2107 V2108 V2108 V2109 V2109 V2110 V2110 V2111 V2111 V2112 V2112 V2113 V2113 V2114 V2114 V2115 V2115 1 VISN PLANO-+/- 4.00D SPHER 4.25-6.00D CYL EA 1 VISN PLANO-+/- 4.00D SPHER OVER 6.00D CYL-LENS 1 VISN PLANO-+/- 4.00D SPHER OVER 6.00D CYL-LENS 1 VISN +/- 4.25-+/ 7.00 SPHER 0.12-2.00D CYL EA 1 VISN +/- 4.25-+/ 7.00 SPHER 0.12-2.00D CYL EA 1 VISN +/-4.25D-+/-7.00D SPHER 2.12-4.00D CYL EA 1 VISN +/-4.25D-+/-7.00D SPHER 2.12-4.00D CYL EA 1 VISN+/- 4.25-+/- 7.00D SPHER 4.25-6.00D CYL EA 1 VISN+/- 4.25-+/- 7.00D SPHER 4.25-6.00D CYL EA 1 VISN +/- 4.25-7.00D SPHERE OVER 6.00D CYL EA 1 VISN +/- 4.25-7.00D SPHERE OVER 6.00D CYL EA 1 VISN +/-7.25-+/-12.00D SPHER 0.25-2.25D CYL EA 1 VISN +/-7.25-+/-12.00D SPHER 0.25-2.25D CYL EA 1 VISN +/- 7.25 +/- 12.00D SPH 2.25D-400D CYL EA 1 VISN +/- 7.25 +/- 12.00D SPH 2.25D-400D CYL EA 1 VISN +/- 7.25 +/- 12.00D SPH 4.25-6.00D CYL EA 1 VISN +/- 7.25 +/- 12.00D SPH 4.25-6.00D CYL EA SINGLE VISION SPHERE OVER +/- 12.00D PER LENS SINGLE VISION SPHERE OVER +/- 12.00D PER LENS LENTICULAR PER LENS SINGLE VISION LENTICULAR PER LENS SINGLE VISION V2118 ANISEIKONIC LENS SINGLE VISION V2118 ANISEIKONIC LENS SINGLE VISION V2121 LENTICULAR LENS PER LENS SINGLE V2121 LENTICULAR LENS PER LENS SINGLE V2199 NOT OTHERWISE CLASSIFIED SINGLE VISION LENS

Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan V2199 V2200 V2200 V2201 V2201 V2202 V2202 V2203 V2203 V2204 V2204 V2205 V2205 V2206 V2206 V2207 V2207 V2208 V2208 V2209 V2209 V2210 V2210 V2211 V2211 V2212 NOT OTHERWISE CLASSIFIED SINGLE VISION LENS SPHERE BIFOCL PLANO TO PLUS/MINUS 4.00D PER LENS SPHERE BIFOCL PLANO TO PLUS/MINUS 4.00D PER LENS SPHERE BIFOCAL +/- 4.12 TO +/- 7.00D PER LENS SPHERE BIFOCAL +/- 4.12 TO +/- 7.00D PER LENS SPHERE BIFOCL +/- 7.12 TO +/- 20.00D PER LENS SPHERE BIFOCL +/- 7.12 TO +/- 20.00D PER LENS BIFOCL PLANO +/- 4.00D SPHER 0.12-2.00D CYL-EA BIFOCL PLANO +/- 4.00D SPHER 0.12-2.00D CYL-EA BIFOCL PLANO +/- 4.00D SPHER 2.12-4.00D CYL-EA BIFOCL PLANO +/- 4.00D SPHER 2.12-4.00D CYL-EA BIFOCL PLANO +/- 4.00D SPHER 4.25-6.00D CYL-EA BIFOCL PLANO +/- 4.00D SPHER 4.25-6.00D CYL-EA BIFOCL PLANO +/- 4.00D SPHER OVR 6.00D CYL-EA BIFOCL PLANO +/- 4.00D SPHER OVR 6.00D CYL-EA BIFOCL +/-4.25-+/-7.00D SPHER 0.12-2.00D CYL-EA BIFOCL +/-4.25-+/-7.00D SPHER 0.12-2.00D CYL-EA BIFOCL +/-4.25-+/-7.00D SPHER 2.12-4.00D CYL-EA BIFOCL +/-4.25-+/-7.00D SPHER 2.12-4.00D CYL-EA BIFOCL +/-4.25-+/-7.00D SPHER 4.25-6.00D CYL-EA BIFOCL +/-4.25-+/-7.00D SPHER 4.25-6.00D CYL-EA BIFOCL +/-4.25-+/-7.00D SPHER OVR 6.00D CYL-LENS BIFOCL +/-4.25-+/-7.00D SPHER OVR 6.00D CYL-LENS BIFOCL +/-7.25-+/-12.00D SPHER 0.25-2.25D CYL-EA BIFOCL +/-7.25-+/-12.00D SPHER 0.25-2.25D CYL-EA BIFOCL +/-7.25-+/-12.00D SPHER 2.25-4.00D CYL-EA

Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan V2212 V2213 V2213 V2214 V2214 BIFOCL +/-7.25-+/-12.00D SPHER 2.25-4.00D CYL-EA BIFOCL +/-7.25-+/-12.00D SPHER 4.25-6.00D CYL-EA BIFOCL +/-7.25-+/-12.00D SPHER 4.25-6.00D CYL-EA BIFOCAL SPHERE OVER +/-12.00D PER LENS BIFOCAL SPHERE OVER +/-12.00D PER LENS V2215 LENTICULAR PER LENS BIFOCAL V2215 LENTICULAR PER LENS BIFOCAL V2218 ANISEIKONIC PER LENS BIFOCAL V2218 ANISEIKONIC PER LENS BIFOCAL V2219 BIFOCAL SEG WIDTH OVER 28MM V2219 BIFOCAL SEG WIDTH OVER 28MM V2220 BIFOCAL ADD OVER 3.25D V2220 BIFOCAL ADD OVER 3.25D V2221 V2221 LENTICULAR LENS PER LENS BIFOCAL LENTICULAR LENS PER LENS BIFOCAL V2299 SPECIALTY BIFOCAL V2300 V2300 V2301 V2301 V2302 V2302 V2303 V2303 V2304 V2304 SPHERE TRIFOCAL PLANO OR +/- 4.00D PER LENS SPHERE TRIFOCAL PLANO OR +/- 4.00D PER LENS SPHERE TRIFOCAL +/- 4.12 TO +/- 7.00D PER LENS SPHERE TRIFOCAL +/- 4.12 TO +/- 7.00D PER LENS SPHERE TRIFOCAL +/- 7.12 TO +/- 20.00 PER LENS SPHERE TRIFOCAL +/- 7.12 TO +/- 20.00 PER LENS TRIFOCL PLANO +/-4.00D SPHER 0.12-2.00D CYL EA TRIFOCL PLANO +/-4.00D SPHER 0.12-2.00D CYL EA TRIFOCL PLANO +/-4.00D SPHER 2.25-4.00D CYL EA TRIFOCL PLANO +/-4.00D SPHER 2.25-4.00D CYL EA

Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan V2305 V2305 V2306 V2306 V2307 V2307 V2308 V2308 V2309 V2309 V2310 V2310 V2311 V2311 V2312 V2312 V2313 V2313 V2314 V2314 TRIFOCL PLANO +/-4.00D SPHER 4.25-6.00 CYL EA TRIFOCL PLANO +/-4.00D SPHER 4.25-6.00 CYL EA TRIFOCL PLANO +/-4.00D SPHER OVR 6.00D CYL EA TRIFOCL PLANO +/-4.00D SPHER OVR 6.00D CYL EA TRIFOCL +/-4.25-+/-7.00D SPHER 0.12-2.00D CYL EA TRIFOCL +/-4.25-+/-7.00D SPHER 0.12-2.00D CYL EA TRIFOCL +/-4.25-+/-7.00D SPHER 2.12-4.00D CYL EA TRIFOCL +/-4.25-+/-7.00D SPHER 2.12-4.00D CYL EA TRIFOCL +/-4.25-+/-7.00D SPHER 4.25-6.00D CYL EA TRIFOCL +/-4.25-+/-7.00D SPHER 4.25-6.00D CYL EA TRIFOCL +/-4.25-+/-7.00D SPHER OVR 6.00D CYL EA TRIFOCL +/-4.25-+/-7.00D SPHER OVR 6.00D CYL EA TRIFOCL +/-7.25-+/-12.00D SPHER 0.25-2.25D CYL E TRIFOCL +/-7.25-+/-12.00D SPHER 0.25-2.25D CYL E TRIFOCL +/-7.25-+/-12.00D SPHER 2.25-4.00D CYL E TRIFOCL +/-7.25-+/-12.00D SPHER 2.25-4.00D CYL E TRIFOCL+/-7.25-+/-12.00D SPHER 4.25-6.00D CYL EA TRIFOCL+/-7.25-+/-12.00D SPHER 4.25-6.00D CYL EA TRIFOCL SPHER OVER +/-12.00D PER LENS TRIFOCL SPHER OVER +/-12.00D PER LENS V2315 LENTICULAR PER LENS TRIFOCAL V2315 LENTICULAR PER LENS TRIFOCAL V2318 ANISEIKONIC LENS TRIFOCAL V2318 ANISEIKONIC LENS TRIFOCAL V2319 TRIFOCAL SEG WIDTH OVER 28 MM V2319 TRIFOCAL SEG WIDTH OVER 28 MM

Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan V2320 TRIFOCAL ADD OVER 3.25D V2320 TRIFOCAL ADD OVER 3.25D V2321 V2321 LENTICULAR LENS PER LENS TRIFOCAL LENTICULAR LENS PER LENS TRIFOCAL V2399 SPECIALTY TRIFOCAL V2399 SPECIALTY TRIFOCAL V2410 V2410 V2430 V2430 V2499 V2499 V2500 V2501 V2502 V2503 V2510 V2511 V2512 V2513 V2520 V2521 V2522 V2523 V2530 V2531 VARIBL ASPHRCTY LENS 1 FULL FLD GLASS/PLASTC LNS VARIBL ASPHRCTY LENS 1 FULL FLD GLASS/PLASTC LNS VARIBL ASPHRCITY LENS BIFOCL FULL FIELD-LENS VARIBL ASPHRCITY LENS BIFOCL FULL FIELD-LENS VARIABLE SPHERICITY LENS OTHER TYPE VARIABLE SPHERICITY LENS OTHER TYPE CONTACT LENS PMMA SPHERICAL PER LENS CONTACT LENS PMMA TORIC/PRISM BALLAST PER LENS CONTACT LENS PMMA BIFOCAL PER LENS CONTACT LENS PMMA COLOR VISION DEFIC PER LENS CONTACT LENS GAS PERMEABLE SPHERICAL PER LENS CNTC LENS GAS PERMEABLE TORIC PRISM BALLST-LENS CONTACT LENS GAS PERMEABLE BIFOCAL PER LENS CNTC LENS GAS PERMEABLE EXTENDED WEAR PER LENS CONTACT LENS HYDROPHILIC SPHERICAL PER LENS CNTC LENS HYDROPHIL TORIC/PRISM BALLST PER LENS CONTACT LENS HYDROPHILIC BIFOCAL PER LENS CONTACT LENS HYDROPHILIC EXTENDED WEAR PER LENS CONTACT LENS SCLERAL GAS IMPERMEABLE PER LENS CONTACT LENS SCLERAL GAS PERMEABLE PER LENS

Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan V2623 PROSTHETIC EYE PLASTIC CUSTOM V2624 V2625 V2626 POLISHING/RESURFACING OF OCULAR PROSTHESIS ENLARGEMENT OF OCULAR PROSTHESIS REDUCTION OF OCULAR PROSTHESIS V2627 SCLERAL COVER SHELL V2628 FABRICATION AND FITTING OF OCULAR CONFORMER V2629 PROSTHETIC EYE OTHER TYPE V2630 V2631 V2632 ANTERIOR CHAMBER INTRAOCULAR LENS IRIS SUPPORTED INTRAOCULAR LENS POSTERIOR CHAMBER INTRAOCULAR LENS V2702 DELUXE LENS FEATURE V2710 V2710 SLAB OFF PRISM GLASS OR PLASTIC PER LENS SLAB OFF PRISM GLASS OR PLASTIC PER LENS V2715 PRISM PER LENS V2715 PRISM PER LENS V2718 V2730 PRESS-ON LENS FRESNELL PRISM PER LENS SPECIAL BASE CURVE GLASS OR PLASTIC PER LENS V2740 Tint, plastic, rose 1 or 2 per lens V2741 Tint, plastic, other than rose 1-2, per lens V2742 Tint, glass rose 1 or 2, per lens V2743 Tint, glass other than rose 1 or 2, per lens V2744 TINT PHOTOCHROMATIC PER LENS V2745 ADD LENS; TINT COLOR SOLID EXCLD PHOTOCHRMATC V2750 ANTIREFLECTIVE COATING PER LENS V2755 U-V LENS PER LENS V2756 EYE GLASS CASE

Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan Kan V2760 V2760 V2761 V2762 SCRATCH RESISTANT COATING PER LENS SCRATCH RESISTANT COATING PER LENS MIRROR COAT TYPE SOLID GRADENT/= LENS MATL-LENS POLARIZATION ANY LENS MATERIAL PER LENS V2770 OCCLUDER LENS PER LENS V2780 OVERSIZE LENS PER LENS V2781 PROGRESSIVE LENS PER LENS V2782 V2782 V2783 V2783 V2784 V2784 V2785 V2786 V2787 V2788 V2790 V2797 LENS INDX 1.54-1.65 PLSTC/1.60-1.79 GLASS LENS LENS INDX 1.54-1.65 PLSTC/1.60-1.79 GLASS LENS LENS INDX >/= 1.66 PLSTC/>/= 1.80 GLASS LENS LENS INDX >/= 1.66 PLSTC/>/= 1.80 GLASS LENS LENS POLYCARBONATE OR EQUAL ANY INDEX PER LENS LENS POLYCARBONATE OR EQUAL ANY INDEX PER LENS PROCESSING PRES&TRANSPORTING CORNEAL TISSUE SPECIALTY OCCUPATIONAL MULTIFOCAL LENS PER LENS ASTIGMATISM CORRECTING FUNCTION INTRAOCULAR LENS PRESBYOPIA CORRECTION FUNCTION INTRAOCULAR LENS AMNIOTIC MEMBRANE SURGICAL RECONSTRUCT PER PROC VISN SPL ACSS &/ SRVC CMPNT ANOTHER HCPCS CODE V2799 VISION SERVICE MISCELLANEOUS V2799 VISION SERVICE MISCELLANEOUS V5120 BINAURAL BODY 00103 00140 ANESTHESIA RECONSTRUCTIVE PROCEDURES OF EYELID ANESTHESIA FOR PROCEDURES ON EYE; NOS Polycarbonate Lenses_KS Polycarbonate Lenses_KS

00142 ANESTHESIA FOR PROCEDURES ON EYE; LENS SURGERY 00144 ANESTHESIA PROCEDURES ON EYE; CORNEAL TRANSPLANT 00145 ANESTHESIA PROCEDURES EYE; VITREORETINAL SURGERY 00147 ANESTHESIA FOR PROCEDURES ON EYE; IRIDECTOMY 00148 ANESTHESIA FOR PROCEDURES ON EYE; OPHTHALMOSCOPY 00300 ANES-INTEG SYST MUSC&NERV HEAD NECK TRUNK;NOS 009 SPEND DOWN ADJUSTMENT 0192T ANT SEGMENT INSERTION DRAINAGE W/O RESERVOIR EXT 022 SKILLED NURSING FACILITY PROSPECTIVE PAYMENT SYSTEM 023 Home health prospective payment system 024 Inpatient rehabilitation facility prospective payment system 100 ALL INCL R&B/ANC 101 ALL INCL R&B 110 ROOM-BOARD/PVT 11042 DEBRIDEMENT; SKIN AND SUBCUTANEOUS TISSUE 11043 DEBRIDEMENT; SKIN SUBCUTANEOUS TISSUE AND MUSCLE 11044 DEBRIDEMENT; SKIN SUBCUT TISSUE MUSCLE&BONE 11045 DBRDMT SUBCUTANEOUS TISSUE EA ADDL 20 SQ CM

11046 DBRDMT M&/F EA ADDL 20 SQ CM 11047 DEBRIDEMENT BONE EA ADDL 20 SQ CM/< 111 MED-SUR-GY/PVT 11100 BX SKIN SUBQ TISSUE &/ MUCOUS MEMBRANE; 1 LESION 11101 BX SKIN SUBQ TISSUE &/ MUCOUS MEMBRANE; EA ADD 112 OB/PVT 11200 REMOVAL SKIN TAGS ANY AREA;TO & INCL 15 LESION 11201 REMOVAL SKIN TAGS ANY AREA;EA ADD 10 LESIONS 113 PEDS/PVT 114 PSYCH/PVT 11440 EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M 0.5CM/< 11441 EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M 0.6-1.0CM 11442 EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M 1.1-2.0CM 11443 EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M 2.1-3.0CM 11444 EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M 3.1-4.0CM 11446 EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M >4.0CM 115 HOSPICE/PVT 116 DETOX/PVT

11640 EXC MAL LES MARG FCE ERS EYELD NSE LPS; 0.5 CM/< 11641 EXC MAL LES MARG FCE ERS EYELD NSE LP;0.6-1.0 CM 11642 EXC MAL LES MARG FCE ERS EYELD NSE LP;1.1-2.0 CM 11643 EXC MAL LES MARG FCE ERS EYELD NSE LP;2.1-3.0 CM 11644 EXC MAL LES MARG FCE ERS EYELD NSE LP;3.1-4.0 CM 11646 EXC MAL LES MARG FCE ERS EYELD NSE LP;OVR 4.0 CM 117 ONCOLOGY/PVT 118 REHAB/PVT 119 OTHER/PVT 120 ROOM-BOARD/SEMI 12011 SIMPL REPR FACE EARS NOSE&/MUCOUS MEMB; < 2.5 CM 12013 SIMPL REPR FACE ERS NOSE&/MUCOUS MEMB;2.6-5.0 CM 12014 SIMPL REPR FCE ERS NOSE&/MUCOUS MEMB; 5.1-7.5 CM 12015 SIMPL REPR FCE ERS NOSE&/MUCOUS MEMB;7.6-12.5 CM 12016 SIMPL REPR FCE ERS NSE&/MUCOUS MEMB;12.6-20.0 CM 12017 SIMPL REPR FCE ERS NSE&/MUCOUS MEMB;20.1-30.0 CM 12018 SIMPL REPR FACE ERS NOSE&/MUCOUS MEMB; > 30.0 CM 12020 TX SUPERFICIAL WOUND DEHISCENCE; SIMPLE CLOSURE

12021 TX SUPERFICIAL WOUND DEHISCENCE; W/PACKING 12051 LAYER CLOS WNDS FACE EARS NOSE&/LIPS; < 2.5 CM 12052 LAYER CLOS WNDS FACE EARS NOSE&/LIPS; 2.6-5.0 CM 12053 LAYER CLOS WNDS FACE EARS NOSE&/LIPS; 5.1-7.5 CM 12054 LAYER CLOS WNDS FCE EARS NOSE&/LIPS; 7.6-12.5 CM 12055 LAYER CLOS WNDS FCE EARS NOSE&/LPS; 12.6-20.0 CM 12056 LAYER CLOS WNDS FCE EARS NOSE&/LPS; 20.1-30.0 CM 12057 LAYER CLOS WNDS FACE EARS NOSE&/LIPS; > 30.0 CM 121 MED-SUR-GY/2BED 122 OB/2BED 123 PEDS/2BED 124 PSYCH/2BED 125 HOSPICE/2BED 126 DETOX/2BED 127 ONCOLOGY/2BED 128 REHAB/2BED 129 OTHER/2BED 130 ROOM-BOARD/3&4BED

131 MED-SUR-GY/3&4BED 13150 REPR CMPLX EYELIDS NOSE EARS&/LIPS; < 1.0 CM 13151 REPR CMPLX EYELIDS NOSE EARS&/LIPS; 1.1-2.5 CM 13152 REPR CMPLX EYELIDS NOSE EARS&/LIPS; 2.6-7.5 CM 13153 REPR CMPLX EYELDS NSE EARS&/LPS;EA ADD 5 CM/LESS 13160 SEC CLOS SURGICAL WOUND/DEHIS EXTENSIVE/COMP 132 OB/3&4BED 133 PEDS/3&4BED 134 PSYCH/3&4BED 135 HOSPICE/3&4BED 136 DETOX/3&4BED 137 ONCOLOGY/3&4BED 138 REHAB/3&4BED 139 OTHER/3&4BED 140 ROOM-BOARD/PVT/DLX 14060 ADJ TISS TRANS EYELDS NOSE&/LIPS; 10 SQ CM/LESS 14061 ADJ TISS TRANS EYELDS NOSE&/LIPS;10.1-30.0 SQ CM 141 MED-SUR-GY/DLX

142 OB/DLX 143 PEDS/DLX 144 PSYCH/DLX 145 HOSPICE/DLX 146 DETOX/DLX 147 ONCOLOGY/DLX 148 REHAB/DLX 149 OTHER/DLX 150 ROOM-BOARD/WARD 15004 PREP SITE F/S/N/H/F/G/M/D GT 1ST 100 SQ CM/1PCT 151 MED-SUR-GY/WARD 15120 SPLT AGRFT F/S/N/H/F/G/M/D GT 1ST 100 CM/</1% 15121 SPLT AGRFT F/S/N/H/F/G/M/D GT EA 100 CM/EA 1 % 152 OB/WARD 15260 FULL THICK GFT NOSE EARS EYELDS&/LPS; 20 SQ CM/< 153 PEDS/WARD 154 PSYCH/WARD 155 HOSPICE/WARD

15576 FORM DIR PEDICLE W/WO TRANSF;EYELDS NSE EARS/LIP 156 DETOX/WARD 15630 DELAY FLAP/SECTIONING FLAP;EYELD NOSE EARS/LIPS 157 ONCOLOGY/WARD 158 REHAB/WARD 15820 BLEPHAROPLASTY LOWER EYELID; 15821 BLPHPLSTY LOWER EYELID; W/EXT HERNIATED FAT PAD 15822 BLEPHAROPLASTY UPPER EYELID; 15823 BLPHPLSTY UPPER EYELID; W/XCESS SKIN WT DOWN LID 159 OTHER/WARD 160 R&B 164 R&B/STERILE 167 R&B/SELF 169 R&B/OTHER 170 NURSERY 17000 DESTRUC BEN/PREMALIG LES OTH THAN SKN TAG; 1 LES 17003 DESTRUC BEN/PREMALIG LES OTH THN SKN TAG;2-14 EA 17004 DESTRUC BEN/PREMALIG OTH THN SKIN TAGS 15/> LES

171 NURSERY/LEVEL I 17106 DESTRUC CUT VASCULAR PROLIFERAT LES; < 10 SQ CM 17107 DESTRUC CUT VASC PROLIFERAT LES; 10.0-50.0 SQ CM 17108 DESTRUC CUT VASC PROLIFERAT LES; > 50.0 SQ CM 17110 DESTRUC FLAT WARTS MOLLUSC CONTAG/MILIA; UP 14 17111 DESTRUC FLAT WARTS MOLLUSC CONTAG/MILIA; 15/>LES 172 NURSERY/LEVEL II 17250 CHEMICAL CAUTERIZATION OF GRANULATION TISSUE 17280 DESTRUC MAL LES FCE ERS EYELD NSE LPS; 0.5 CM/< 17281 DESTRUC MAL LES FCE ERS EYELD NSE LPS;0.6-1.0 CM 17282 DESTRUC MAL LES FCE ERS EYELD NSE LPS;1.1-2.0 CM 17283 DESTRUC MAL LES FCE ERS EYELD NSE LPS;2.1-3.0 CM 17284 DESTRUC MAL LES FCE ERS EYELD NSE LPS;3.1-4.0 CM 17286 DESTRUC MAL LES FCE ERS EYELD NSE LPS; > 4.0 CM 173 NURSERY/LEVEL III 17304 MOHS SURG; 1 STAGE FRESH TISS TECH UP 5 SPECIMEN 17305 MOHS SURG; 2 STAGE FIX/FRESH TISS UP 5 SPECIMEN 17306 MOHS SURG; 3 STAGE FIX/FRESH TISS UP 5 SPECIMEN

17307 MOHS SURG; ADD STAGE UP 5 SPECIMEN EA STAGE 17310 MOHS SURG; EA ADD AFTER 1ST 5 SPECIMEN ANY STAGE 174 NURSERY/LEVEL IV 179 NURSERY/OTHER 180 LEAVE OF ABSENCE 182 LOA/PT CONV CHGS BILLABLE 183 LOA/THERAP 184 LOA/ICF/MR 185 LOA/NURS HOME 189 LOA/OTHER 190 SUBACUTE 191 SUBACUTE/LEVEL I 192 SUBACUTE/LEVEL II 193 SUBACUTE/LEVEL III 194 SUBACUTE/LEVEL IV 199 SUBACUTE/OTHER 200 INTENSIVE CARE 201 ICU/SURGICAL

202 ICU/MEDICAL 203 ICU/PEDS 204 ICU/PSTAY 206 ICU/INTERMEDIATE 207 ICU/BURN CARE 208 ICU/TRAMA 209 ICU/OTHER 210 CORONARY CARE 211 CCU/MYO INFARC 212 ALL INCL ANCIL 212 CCU/PULMONARY 213 CCU/TRANSPLANT 214 CCU/INTERMEDIATE 219 CCU/OTHER 220 SPECIAL CHARGES 221 ADMIT CHARGE 222 TECH SUPPT CHG 223 UR CHARGE

224 LATE DISCH/MED NEC 229 OTHER SPEC CHG 230 NURSING INCREM 231 NUR INCR/NURSERY 232 NUR INCR/OB 233 NUR INCR/ICU 234 NUR INCR/CCU 235 NUR INCR/HOSPICE 239 NUR INCR/OTHER 249 ALL INCL ANCIL/OTHER 250 PHARMACY 251 DRUGS/GENERIC 252 DRUGS/NONGENERIC 253 DRUGS/TAKEHOME 254 DRUGS/INCIDENT ODX 255 DRUGS/INCIDENT RAD 256 DRUGS/EXPERIMT 257 DRUGS/NONPSCRPT

258 IV SOLUTIONS 259 DRUGS/OTHER 260 IV THERAPY 261 IV THER/INFSN PUMP 262 IV THER/PHARM/SVC 263 IV THER/DRUG/SUPPLY DELV 264 IV THER/SUPPLIES 269 IV THERAPY/OTHER 270 MED-SURG SUPPLIES 271 NONSTER SUPPLY 272 STERILE SUPPLY 273 TAKEHOME SUPPLY 274 PROSTH/ORTH DEV 275 PACE MAKER 276 INTR OC LENS 277 O2/TAKEHOME 278 SUPPLY/IMPLANTS 279 SUPPLY/OTHER

280 ONCOLOGY 289 ONCOLOGY/OTHER 290 MED EQUIP/DURAB 291 MED EQUIP/RENT 292 MED EQUIP/NEW 293 MED EQUIP/USED 294 MED EQUIP/SUPPLIES/DRUGS 299 MED EQUIP/OTHER 300 LABORATORY 301 LAB/CHEMISTRY 302 LAB/IMMUNOLOGY 303 LAB/RENAL HOME 304 LAB/NR DIALYSIS 305 LAB/HEMATOLOGY 306 LAB/BACT-MICRO 307 LAB/UROLOGY 309 LAB/OTHER 310 PATHOLOGY LAB

311 PATHOL/CYTOLOGY 312 PATHOL/HYSTOL 314 PATHOL/BIOPSY 319 PATHOL/OTHER 320 DX X-RAY 321 DX X-RAY/ANGIO 322 DX X-RAY/ARTH 323 DX X-RAY/ARTER 324 DX X-RAY/CHEST 329 DX X-RAY/OTHER 330 RX X-RAY 331 CHEMOTHER/INJ 332 CHEMOTHER/ORAL 333 RADIATION RX 335 CHEMOTHERP-IV 339 RX X-RAY/OTHER 340 NUCLEAR MEDICINE 341 NUC MED/DX

342 NUC MED/RX 343 Diagnostic rediopharmaceuticals 344 THERAPEUTIC PHARMACEUTICALS 349 NUC MED/OTHER 350 CT SCAN 351 CT SCAN/HEAD 352 CT SCAN/BODY 359 CT SCAN/OTHER 360 OR SERVICES 361 OR/MINOR 362 OR/ORGAN TRANS 367 OR/KIDNEY TRANS 369 OR/OTHER 370 ANESTHESIA 371 ANESTHE/INCIDENT RAD 372 ANESTHE/INCIDENT ODX 374 ANESTHE/ACUPUNC 379 ANESTHE/OTHER

380 BLOOD 381 BLOOD/PKD RED 382 BLOOD/WHOLE 383 BLOOD/PLASMA 384 BLOOD/PALTELETES 385 BLOOD/LEUCOCYTES 386 BLOOD/COMPONENTS 387 BLOOD/DERIVATIVES 389 BLOOD/OTHER 390 BLOOD/STOR-PROC 391 BLOOD/ADMIN 399 BLOOD/OTHER STOR 400 IMAGE SERVICE 401 MAMMOGRAPHY 402 ULTRASOUND 403 SCR MAMMOGRAPHY/GEN MAMMO 404 PET SCAN 409 OTHER IMAG SVS

410 RESPIRATORY SVC 412 INHALATION SVC 413 HYPERBARIC 02 419 OTHER RESPIR SVS 420 PHYSICAL THERP 421 PHYS THERP/VISIT 422 PHYS THERP/HOUR 423 PHYS THERP/GROUP 424 PHYS THERP/EVAL 429 OTHER PHYS THERP 430 OCCUPATION THER 431 OCCUP THERP/VISIT 432 OCCUP THERP/HOUR 433 OCCUP THERP/GROUP 434 OCCUP THERP/EVAL 439 OTHER OCCUP THER 440 SPEECH PATHOL 441 SPEECH PATH/VISIT

442 SPEECH PATH/HOUR 443 SPEECH PATH/GROUP 444 SPEECH PATH/EVAL 449 OTHER SPEECH PAT 450 EMERG ROOM 451 ER/EMTALA 452 ER/BEYOND EMTALA 456 URGENT CARE 459 OTHER EMER ROOM 460 PULMONARY FUNC 469 OTHER PULMON FUNC 470 AUDIOLOGY 471 AUDIOLOGY/DX 472 AUDIOLOGY/RX 479 OTHER AUDIOL 480 CARDIOLOGY 481 CARDIAC CATH LAB 482 STRESS TEST

483 ECHOCARDIOLOGY 489 OTHER CARDIOL 490 AMBUL SURG 499 OTHER AMBL SURG 500 OUTPATIENT SVS 509 OUTPATIENT/OTHER 510 CLINIC 511 CHRONIC PAIN CL 512 DENTAL CLINIC 513 PSYCH CLINIC 514 OB-GYN CLINIC 515 PEDS CLINIC 516 URGENT CLINIC 517 FAMILY CLINIC 519 OTHER CLINIC 520 FREESTAND CLINIC 521 RURAL/CLINIC 522 RURAL/HOME

523 FR/STD FAMILY CLINIC 526 FR/STD URGENT CLINIC 529 OTHER FR/STD CLINIC 530 OSTEOPATH SVS 531 OSTEOPATH RX 539 OTHER OSTEOPATH 540 AMBULANCE 541 Supplies 542 Medical Transport 544 AMBUL/OXY 545 AIR AMBULANCE 546 AMBUL/NEO-NATAL 547 AMBUL/PHARMACY 548 AMBUL/TELEPHONE EKG 549 OTHER AMBULANCE 550 SKILLED NURSING 551 SKILLED NURS/VISIT 552 SKILLED NURS/HOUR

559 SKILLED NURS/OTHER 560 MED SOCIAL SVS 561 MED SOC SERV/VISIT 562 MED SOC SERV/HOUR 569 MED SOC SERV/OTHER 570 AIDE/HOME HEALTH 571 AIDE/HOME HLTH/VISIT 572 AIDE/HOME HLTH/HOUR 579 AIDE/HOME HLTH/OTHER 580 VISIT/HOME HEALTH 581 VISIT/HOME HLTH/VISIT 582 VISIT/HOME HLTH/HOUR 589 VISIT/HOME HLTH/OTHER 590 UNIT/HOME HEALTH 599 UNIT/HOME HLTH/OTHER 600 02/HOME HEALTH 601 02/EQUIP/SUPPL/CONT 602 02/STAT EQUIP/UNDER 1 LPM

603 02/STAT EQUIP/OVER 4 LPM 604 02/STAT EQUIP/PORT ADD-ON 610 MRI 611 MRI - BRAIN 612 MRI - SPINE 614 MRI - OTHER 615 MRA - HEAD AND NECK 616 MRA - LOWER EXTREMITIES 619 MRI - OTHER 621 MED-SUR SUPP/INCIDNT RAD 622 MED-SUR SUPP/INCIDNT ODX 623 SURG DRESSING 624 IDE 630 DRUGS 631 DRUG/SNGLE 632 DRUG/MULT 633 DRUG/RSTR 634 DRUG/EPO/<=10,000 UNITS

635 DRUG/EPO/>=10,000 UNITS 636 DRUGS/DETAIL CODE 637 DRUGS/SELFADMIN 640 IV THERAPY SVC 641 NON RT NURSING/CENTRAL 642 IV SITE CARE/CENTRAL 643 IV STRT/CHNG/PERIPHAL 644 NONRT NURSING/PERIPHRL 645 TRNG/PT/CARGVR/CENTRAL 646 TRNG DSBLPT/CENTRAL 647 TRNG/PT/CARGVR/PERIPHRL 648 TRNG/DSBLPAT/PERIPHRL 649 OTHER IV THERAPY SVC 650 HOSPICE 65091 EVISCERATION OF OCULAR CONTENTS; WITHOUT IMPLANT 65093 EVISCERATION OF OCULAR CONTENTS; WITH IMPLANT 651 HOSPICE/RTN HOME 65101 ENUCLEATION OF EYE; WITHOUT IMPLANT

65103 ENUCLEAT EYE; W/IMPLANT MUSC NOT ATTCH IMPLANT 65105 ENUCLEATION EYE; W/IMPLANT MUSCLES ATTCH IMPLANT 65110 EXENTERATION ORBIT REMOVAL ORB CONTENTS; ONLY 65112 EXENTERATION ORBITAL CONTENTS; W/REMOV BONE 65114 EXENTERAT ORBITAL CONTENTS; W/MUSC/MYOCUT FLAP 65125 MODIFICATION OCULR IMPLANT W/PLCMT/REPLCMT PEGS 65130 INSRT OCULAR IMPLNT SECNDRY; AFTER EVISCERATION 65135 INSRT OCULAR IMPLNT SECNDRY; AFTER ENUCLEATION 65140 INSRT OCULAR IMPLNT; ENUCLEAT- MUSC ATTACH-IMPLT 65150 REINSERTION OCULAR IMPLANT; W/WO CONJUNCT GRAFT 65155 REINSRT OCULAR IMPLNT; W/FOREIGN MAT REINFORCE 65175 REMOVAL OF OCULAR IMPLANT 652 HOSPICE/CTNS HOME 65205 REMOVAL FB EXTERNAL EYE; CONJUNCT SUPERFICIAL 65210 REMV FB EXT EYE; CONJUNC EMBEDDED/SUBCONJUNC 65220 REMOVAL FB EXTERNAL EYE; CORNEAL W/O SLIT LAMP 65222 REMOVAL FB EXTERNAL EYE; CORNEAL W/SLIT LAMP 65235 REMOVAL FB INTRAOCULAR; FROM ANT CHAMB EYE/LENS

65260 REMV FB IO; POST SEGMT-MAGNETIC EXTRACTION 65265 REMV FB INTRAOCULR; POST SEG NONMAGNETIC XTRAC 65270 REPR LACERAT; CONJUNC W/WO LACERAT SCLERA 65272 REPR LAC; CONJUNCT MOBILIZ&REARNGMENT W/O HOSP 65273 REPR LAC; CONJUNCT MOBILIZ&REARNGMENT W/HOSP 65275 REPR LAC; CORN NONPERFORATING W/WO REMOVAL FB 65280 REPR LACERAT; CORNEA PERFORATING WO UVEAL TISS 65285 REPR LACERAT; CORNEA W/REPOSIT/RESECT UVEAL TISS 65286 REPR LAC; APPLIC TISS GLUE WNDS CORN &OR SCLERA 65290 REPR WOUND XTRAOCULR MUSC TENDON &OR TENONS CAP 65400 EXCISION OF LESION CORNEA EXCEPT PTERYGIUM 65410 BIOPSY OF CORNEA 65420 EXCISION/TRANSPOSITION PTERYGIUM; WITHOUT GRAFT 65426 EXCISION OR TRANSPOSITION OF PTERYGIUM; W/GRAFT 65430 SCRAPING OF CORNEA DIAGNOSTIC SMEAR &OR CULTURE 65435 REMOVAL CORNEAL EPITHELIUM; W/WO CHEMOCAUT 65436 REMOVAL CORNEAL EPITHEL; W/APPLIC CHELATING AGT 65450 DESTRUC LES CORN CRYOTHAPY PHOTOCOAG/THERMOCAUT

655 HOSPICE/IP RESPITE 656 HOSPICE/IP NON RESPITE 65600 MULTIPLE PUNCTURES OF ANTERIOR CORNEA 657 HOSPICE/PHYSICIAN 65710 KERATOPLASTY; LAMELLAR 65730 KERATOPLASTY; PENETRATING EXCEPT IN APHAKIA 65750 KERATOPLASTY; PENETRATING IN APHAKIA 65755 KERATOPLASTY; PENETRATING IN PSEUDOPHAKIA 65756 KERATOPLASTY ENDOTHELIAL 65757 BACKBENCH PREPJ CORNEAL ENDOTHELIAL ALLOGRAFT 65760 KERATOMILEUSIS 65765 KERATOPHAKIA 65767 EPIKERATOPLASTY 65770 KERATOPROSTHESIS 65771 RADIAL KERATOTOMY 65772 CORNL RELAXING INCI CORR SURGLY INDUCD ASTIGMA 65775 CORNL WEDGE RESECTION CORR SURGLY INDUCD ASTIGMA 65778 PLACE AMNIOTIC MEMB OCULAR SURFACE SELF RETAIN

65779 PLACE AMNIOTIC MEMBRANE OCULAR SURFACE SUTURED 65780 OCULR SURFCE RECNSTR; AMNIOTIC MEMBRANE TPLNT 65781 OCULR SURFCE RECNSTR; LIMBAL STEM CELL ALLOGFT 65782 OCULR SURFCE RECNSTR; LIMBAL CONJUNCT AUTOGFT 658 HOSPICE ROOM AND BOARD - NURSING FACILITY 65800 PARACEN ANT CHAMB EYE-SEP PROC; W/DX ASPIR AQUES 65805 PARACEN ANT CHAMB EYE-SEP PROC; W/TX RLSE AQUEOS 65810 PARACEN ANT CHAMB EYE-SEP PROC; W/REMV VITREOUS 65815 PARACENTESIS ANT CHAMB EYE-SEP PROC; W/REMV BLD 65820 GONIOTOMY 65850 TRABECULOTOMY AB EXTERNO 65855 TRABECULOPLASTY LASER SURGERY 1 OR MORE SESSIONS Laser Scanning_KS 4 365 DAYS 65860 SEVERING ADHES ANTERIOR SEGMENT LASER TECHNIQUE 65865 SEVERING ADHESIONS-SEP PROC; GONIOSYNECHIAE 65870 SEVERING ADHESIONS-SEP PROC; ANT SYNECHIAE 65875 SEVERING ADHESIONS-SEP PROC; POST SYNECHIAE 65880 SEVERING ADHESIONS-SEP PROC; CORNEOVITREAL 659 HOSPICE/OTHER

65900 REMOVAL EPITHELIAL DOWNGROWTH ANT CHAMBER EYE 65920 REMOVAL IMPLANTED MATERIAL ANTERIOR SEGMENT EYE 65930 REMOVAL OF BLOOD CLOT ANTERIOR SEGMENT OF EYE 660 RESPITE CARE 66020 INJ ANTERIOR CHAMBER OF EYE SEP PROC; AIR/LIQUID 66030 INJECTION ANTERIOR CHAMBER OF EYE SEP PROC; MED 661 RESPITE/SKILLED NURSE 66130 EXCISION OF LESION SCLERA 66150 FISTULIZ SCLERA GLAUC; TREPHINATION W/IRIDECTOMY 66155 FISTULIZ SCLERA GLAUC; THERMOCAUT W/IRIDECTOMY 66160 FISTULIZAT SCLERA; SCLERECTOMY W/PUNCH W/IRIDECT 66165 FISTULIZ SCLERA GLAUC; IRIDENCLEISIS/IRIDOTASIS 66170 FISTULIZAT SCLER;TRABECULECT AB EXT-NO OTHR SURG 66172 FISTULIZAT SCLERA; TRABECULECT AB EXT W/SCARRING 66174 TRLUML DILAT AQUEOUS CANAL W/O DEV/STNT 66175 TRLUML DILAT AQUEOUS CANAL W/DEV/STNT 66180 AQUEOUS SHUNT TO EXTRAOCULAR RESERVOIR 66185 REVISION AQUEOUS SHUNT TO EXTRAOCULAR RESERVOIR

662 RESPITE/HMEAID/HMEMKE 66220 REPAIR OF SCLERAL STAPHYLOMA; WITHOUT GRAFT 66225 REPAIR OF SCLERAL STAPHYLOMA; WITH GRAFT 66250 REVIS/REPR OPERATIVE WOUND ANT SEGMT 66500 IRIDOTOMY STAB INCI-SEP PROC; EXCEPT TRANSFIXION 66505 IRIDOTOMY-SEP PROC; W/TRANSFIXION AS IRIS BOMBE 66600 IRIDECT W/CORNEOSCLERAL/CORNL SECT; REMOVL LES 66605 IRIDECT W/CORNEOSCLERAL/CORNL SECTION; W/CYCLECT 66625 IRIDECT-CORNEOSCLERL/CORNL SECT; PERIPH GLAUC-SP 66630 IRIDECT-CORNEOSCLERAL/CORNL SECT;SECTOR GLAUC-SP 66635 IRIDECT W/CORNEOSCLERAL/CORNEAL SECT; OPTICAL-SP 66680 REPAIR OF IRIS CILIARY BODY 66682 SUTURE IRIS CILIARY BODY-SEP PROC W/RETRIEVL SUT 66700 CILIARY BODY DESTRUCTION; DIATHERMY 66710 CILIARY BDY DESTRUC; CYCLOPHOTOCOAG TRANSSCLERAL 66711 CILIARY BODY DESTRCTION; CYCLOPHOTOCOAGULAT ENDO 66720 CILIARY BODY DESTRUCTION; CRYOTHERAPY 66740 CILIARY BODY DESTRUCTION; CYCLODIALYSIS

66761 IRIDOTOMY/IRIDECTOMY BY LASER SURGERY Laser Scanning_KS 4 365 DAYS 66762 IRIDOPLASTY BY PHOTOCOAGULATION 66770 DESTRUCTION CYST OR LESION IRIS OR CILIARY BODY 66820 DISCISSION SEC MEMB CATARACT; STAB INCI TECH 66821 DISCISSION SEC MEMB CATARACT; LASER SURGERY Laser Scanning_KS 4 365 DAYS 66825 REPSTN INTRAOCULR LENS PROSTH RQR INCI-SEP PROC 66830 REMV 2ND MEMBRN CATARACT W/CORNEO-SCLERAL SECT 66840 REMOVAL LENS MATL; ASPIR TECHNIQUE 1/MORE STAGES 66850 REMOVL LENS MATL; PHACOFRAGATION TECH W/ASPIR 66852 REMOVL LENS MATL; PARS PLANA APPRCH W/WO VITRECT 66920 REMOVAL OF LENS MATERIAL; INTRACAPSULAR 66930 REMOVAL LENS MATERIAL; INTRACAPSULAR DISLOC LENS 66940 REMOVAL OF LENS MATERIAL; EXTRACAPSULAR 66982 EXTRACAP CATARACT REMV W/IOL- COMPLX-DIFF TECH 66983 INTRACAPSULAR CATARACT EXTRAC W/INSRT IOL PROSTH 66984 EXTRACAPSULAR CATARACT REMV W/INSRT IOL PROSTH 66985 INSERT IOL PROSTHESIS- SECONDARY IMPLANT 66986 EXCHANGE OF INTRAOCULAR LENS

66999 UNLISTED PROCEDURE ANTERIOR SEGMENT OF EYE 670 OP SPEC RES 67005 REMOVAL VITREOUS ANT APPROACH; PARTIAL REMOVAL 67010 REMV VITREOUS ANT; SUBTL REMV W/MECH VITRECT 67015 ASPIRAT/RELEASE VITREOUS/SUBRETINAL FLUID 67025 INJ VITREOUS SUBSTITUTE-W/WO ASPIRAT-SEP PROC 67027 IMPLANT INTRAVITREAL DRUG DELIVERY SYSTEM 67028 INTRAVITREAL INJECTION OF A PHARMACOLOGIC AGENT 67030 DISCISSION VITREOUS STRANDS PARS PLANA APPROACH 67031 SEVERING VITREOUS STRANDS/MEMBRN-LASER SURG Laser Scanning_KS 4 365 DAYS 67036 VITRECTOMY MECHANICAL PARS PLANA APPROACH; 67039 VITRECTOMY MECH; W/FOCAL ENDOLASER PHOTOCOAGULAT 67040 VITRECTOMY MECH; W/ENDOLASER PANRETINAL PHOTOCOA 67041 VITRECTOMY PARS PLANA REMOVE PRERETINAL MEMBRANE 67042 VITRECTOMY PARS PLANA REMOVE INT MEMB RETINA 67043 VITRECTOMY PARS PLANA REMOVE SUBRETINAL MEMBRANE 671 OP SPEC RES/HOSP BASED 67101 REPR RETINAL DETACHMENT; CRYOTHERAPY/DIATHERMY

67105 REPR RETINAL DETACHMENT; PHOTOCOAGULATION 67107 REPR RETINAL DETACHMENT; SCLERAL BUCKLING 67108 REPR RETINAL DETACHMENT; W/VITRECTOMY ANY METHD 67110 REPAIR RET DETACH; INJECTION AIR/OTHER GAS 67112 REPR RETINAL DETACHMENT; PREV RET DETACH REPR 67113 RPR COMPLEX RETINA DETACH VITRECTOMY & MEMB PEEL 67115 RELEASE OF ENCIRCLING MATERIAL 67120 REMOVAL IMPL MATERIAL POST SEGMENT; XTRAOCULR 67121 REMOVAL IMPL MATERIAL POST SEGMENT; INTRAOCULR 67141 PROPHYLAXIS RETINL DETACH W/O DRAIN; CRYOTHERAPY 67145 PROPH RET DETACH W/O DRN 1/MORE SESSS; PHOTOCOAG 672 OP SPEC RES/CONTRACTED 67208 DESTRCT LOCALIZ LES RETINA; CRYOTHERAPY/DIATHERM Laser Scanning_KS 4 365 DAYS 67210 DESTRUC LOC LES RETINA 1/MORE SESSS; PHOTOCOAG Laser Scanning_KS 4 365 DAYS 67218 DESTRCT LOCALIZ LES RETINA; RADIATION-IMPLNT 67220 DESTRUC LOC LES CHOROID; PHOTOCOAG 1/MORE SESS Laser Scanning_KS 4 365 DAYS 67221 DESTRUC LOC LESION CHOROID; PHOTODYNAMIC THERAPY 67225 DSTRUC LOC LES CHOROID; PHOTODYN TX 2 EYE 1 SESS

67227 DESTRCT PROGRESSIVE RETINOPATHY; CRYOTHERAPY 67228 DESTRCT PROGRESSIVE RETINOPATHY; PHOTOCOAGULAT 67229 EXTENSIVE RETINOPATHY 1+ SESS PRETERM INFANT 67250 SCLERAL REINFORCEMENT; WITHOUT GRAFT 67255 SCLERAL REINFORCEMENT; WITH GRAFT 67299 UNLISTED PROCEDURE POSTERIOR SEGMENT 67311 STRABISMUS SURGERY R/R PROC; 1 HORIZONTAL MUSCLE 67312 STRABISMUS SURGERY R/R PROC; 2 HORIZONTAL MUSC 67314 STRABISMUS SURGERY R/R PROC; 1 VERTICAL MUSCLE 67316 STRAB SURGERY R/R PROC; TWO/MORE VERTICAL MUSC 67318 STRAB SURGERY ANY PROC SUPERIOR OBLIQUE MUSCLE 67320 TRANSPOSITION PROCEDURE ANY EXTRAOCULAR MUSCLE 67331 STRABISMUS SURG-PT W/PREV EYE SURGERY/INJURY 67332 STRABISMUS SURG-PT W/SCARRING EXTRAOCULAR MUSC 67334 STRAB SURG POST FIX SUT TECH W/WO MUSC RECESSION 67335 PLCMT ADJUSTABLE SUTURE- DURING STRABISMUS SURG 67340 STRABISMUS SURG EXPLOR &/OR REPR DETACHED MUSC 67343 RLSE EXT SCAR TISS W/O DETACH XTRAOCULR MUSC-SP

67345 CHEMODENERVATION OF EXTRAOCULAR MUSCLE 67346 BIOPSY EXTRAOCULAR MUSCLE 67350 BIOPSY OF EXTRAOCULAR MUSCLE 67399 UNLISTED PROCEDURE OCULAR MUSCLE 67400 ORBITOTOMY WITHOUT BONE FLAP; EXPL W/WO BX 67405 ORBITOTOMY WITHOUT BONE FLAP; WITH DRAINAGE ONLY 67412 ORBITOTOMY WITHOUT BONE FLAP; W/REMOVAL LESION 67413 ORBITOTOMY WITHOUT BONE FLP; W/REMOVAL FB 67414 ORBITOT W/O BONE FLP; W/REMOVAL BONE DECOMPRS 67415 FINE NEEDLE ASPIRATION OF ORBITAL CONTENTS 67420 ORBITOT W/BN FLP/WINDOW LAT APPRCH; W/REMOVL LES 67430 ORBITOT W/BN FLP/WINDOW LAT APPRCH; W/REMOVAL FB 67440 ORBITOTOMY W/BONE FLP/WINDOW LAT APPRCH; W/DRAIN 67445 ORBITOTOMY W/BONE FLAP/WINDOW; W/REMV BONE 67450 ORBITOT W/BN FLP/WINDOW LAT APPRCH; EXPL W/WO BX 67500 RETROBULBAR INJECTION; MEDICATION 67505 RETROBULBAR INJECTION; ALCOHOL 67515 INJECTION MEDICATION/OTH SUBSTANCE IN TENONS CAP

67550 ORBITAL IMPLANT; INSERTION 67560 ORBITAL IMPLANT; REMOVAL OR REVISION 67570 OPTIC NERVE DECOMPRESSION 67599 UNLISTED PROCEDURE ORBIT 67700 BLEPHAROTOMY DRAINAGE OF ABSCESS EYELID 67710 SEVERING OF TARSORRHAPHY 67715 CANTHOTOMY 67800 EXCISION OF CHALAZION; SINGLE 67801 EXCISION OF CHALAZION; MULTIPLE SAME LID 67805 EXCISION OF CHALAZION; MULTIPLE DIFFERENT LIDS 67808 EXC CHALAZION; UNDER GEN ANES- &/ RQR HOSP 1/MX 67810 BIOPSY OF EYELID 67820 CORRECTION OF TRICHIASIS; EPILATION FORCEPS ONLY 67825 CORRECT TRICHIASIS; EPILATION OTH THAN FORCEPS 67830 CORRECTION OF TRICHIASIS; INCISION OF LID MARGIN 67835 CORRECT TRICHIASIS; INCS LID MARGIN W/MEMBRN GFT 67840 EXCISION LESION EYELID W/O CLOS/W/SMPL DIR CLOS 67850 DESTRUCTION OF LESION OF LID MARGIN

67875 TEMPORARY CLOSURE OF EYELIDS BY SUTURE 67880 CONSTRUCT INTERMARGINAL ADHESIONS 67882 CONSTRCT INTERMARG ADHESIONS; W/TRANSPOSIT TARSL 679 OP SPEC RES/OTHER 67900 REPAIR OF BROW PTOSIS 67901 RPR BLPOS FRNTIS MUSC SUTR/OTH MATRL 67902 RPR BLPOS FRNTIS MUSC AUTOL FSCAL SLING 67903 REP BLEPHAROPT; LEVATOR RES/ADVMENT INTRL APPRCH 67904 REPR BLEPHAROPT; LEVATOR RES/ADVMENT EXT APPRCH 67906 REPR BLEPHAROPT; SUP RECTUS TECH W/FASCL SLING 67908 REPR BLEPHAROPTOSIS; CONJUNC- TARSO-MULLER'S 67909 REDUCTION OF OVERCORRECTION OF PTOSIS 67911 CORRECTION OF LID RETRACTION 67912 CORR LAGOPHTHALMOS W/IMPL UPPER EYELID LID LOAD 67914 REPAIR OF ECTROPION; SUTURE 67915 REPAIR OF ECTROPION; THERMOCAUTERIZATION 67916 REPAIR ECTROPION; EXCISION TARSAL WEDGE 67917 REPAIR OF ECTROPION; EXTENSIVE

67921 REPAIR OF ENTROPION; SUTURE 67922 REPAIR OF ENTROPION; THERMOCAUTERIZATION 67923 REPAIR ENTROPION; EXCISION TARSAL WEDGE 67924 REPAIR OF ENTROPION; EXTENSIVE 67930 SUTURE RECENT WOUND EYELID DIR CLOS; PART THICK 67935 SUTURE RECENT WOUND EYELID DIR CLOS; FULL THICK 67938 REMOVAL OF EMBEDDED FOREIGN BODY EYELID 67950 CANTHOPLASTY 67961 EXC & REPR EYELID; UP TO 1/4 LID MARGIN 67966 EXC & REPR EYELID > 1/4 LID MARGIN 67971 RECON EYELID FULL THICK; UP TO 2/3 LID 1 STAGE 67973 RECON EYELID; TOT LID LOWER 1 STAGE/1ST STAGE 67974 RECON EYELID; TOT LID UPPER 1 STAGE/1ST STAGE 67975 RECON EYELID FULL THICK-TRANSF FLAP; 2ND STAGE 67999 UNLISTED PROCEDURE EYELIDS 68020 INCISION OF CONJUNCTIVA DRAINAGE OF CYST 68040 EXPRESSION OF CONJUNCTIVAL FOLLICLES 681 LEVEL 1

68100 BIOPSY OF CONJUNCTIVA 68110 EXCISION OF LESION CONJUNCTIVA; UP TO 1 CM 68115 EXCISION OF LESION CONJUNCTIVA; OVER 1 CM 68130 EXCISION LESION CONJUNCTIVA; W/ADJACENT SCLERA 68135 DESTRUCTION OF LESION CONJUNCTIVA 682 LEVEL 2 68200 SUBCONJUNCTIVAL INJECTION 683 LEVEL 3 68320 CONJUNCTPLSTY; W/CONJUNCT GRAFT/EXT REARNGMENT 68325 CONJUNCTPLSTY; W/BUCCAL MUCOUS MEMBRANE GRAFT 68326 CONJUNCTIVOPLASTY RECON CUL- DE-SAC; W/GFT 68328 CONJUNCTIVOPLASTY RECON CUL- DE-SAC; W/BUCCAL GFT 68330 REPAIR SYMBLEPHARON; CONJUNCTPLSTY WITHOUT GRAFT 68335 REPR SYMBLEPHARON; W/FREE GFT CONJUNC/BUCCAL 68340 REPR SYMBLEPHARON; DIVIS SYMBLEPHARON W/WO INSRT 68360 CONJUNCTIVAL FLAP; BRIDGE OR PARTIAL 68362 CONJUNCTIVAL FLAP; TOTAL 68371 HARVESTING CONJUNCTIVAL ALLOGRAFT LIVING DONOR

68399 UNLISTED PROCEDURE CONJUNCTIVA 684 LEVEL 4 68400 INCISION DRAINAGE OF LACRIMAL GLAND 68420 INCISION DRAINAGE OF LACRIMAL SAC 68440 SNIP INCISION OF LACRIMAL PUNCTUM 68500 EXCISION OF LACRIMAL GLAND EXCEPT TUMOR; TOTAL 68505 EXCISION OF LACRIMAL GLAND EXCEPT TUMOR; PARTIAL 68510 BIOPSY OF LACRIMAL GLAND 68520 EXCISION OF LACRIMAL SAC 68525 BIOPSY OF LACRIMAL SAC 68530 REMOVAL FB/DACRYOLITH LACRIMAL PASSAGES 68540 EXCISION LACRIMAL GLAND TUMOR; FRONTAL APPROACH 68550 EXCISION LACRIMAL GLAND TUMOR; INVLV OSTEOTOMY 68700 PLASTIC REPAIR OF CANALICULI 68705 CORRECTION OF EVERTED PUNCTUM CAUTERY 68720 DACRYOCYSTORHINOSTOMY 68745 CONJUNCTIVORHINOSTOMY; WITHOUT TUBE 68750 CONJUNCTIVORHINOSTOMY; W/INSERTION TUBE OR STENT

68760 CLOS LAC PUNCTUM; THERMOCAUT LIG/LASER SURGERY 68761 CLOSURE OF THE LACRIMAL PUNCTUM; BY PLUG EACH 68770 CLOSURE OF LACRIMAL FISTULA 68801 DILATION OF LACRIMAL PUNCTUM W/WO IRRIGATION 68810 PROBING OF NLD WITH OR WITHOUT IRRIGATION; 68811 PROBING NLD W/WO IRRIGATION; RQR GEN ANESTHESIA 68815 PROBING NLD W/WO IRRIG; W/INSRTION TUBE/STENT 68816 PROBE NASOLACRIMAL DUCT WITH CATHETER DILATION 68840 PROBING OF LACRIMAL CANALICULI W/WO IRRIGATION 68850 INJECTION OF CONTRAST MEDIUM DACRYOCYSTOGRAPHY 68899 UNLISTED PROCEDURE LACRIMAL SYSTEM 689 OTHER TRAUMA RESPONSE 700 CAST ROOM 709 OTHER CAST ROOM 710 RECOVERY ROOM 719 OTHER RECOV RM 720 DELIVROOM/LABOR 721 LABOR

722 DELIVERY ROOM 723 CIRCUMCISION 724 BIRTHING CENTER 729 OTHER/DELIV-LABOR 730 EKG/ECG 731 HOLTER MONT 732 TELEMETRY 739 OTHER EKG-ECG 740 EEG 749 OTHER EEG 750 GASTR-INTS SVS 759 OTHER GASTRO-INTS 760 TREATMENT/OBSERVATION RM 761 TREATMENT RM 762 OBSERVATION RM 76510 OPHTHALMIC US DX; B-SCAN&QUAN A-SCAN SAME ENCNTR 76511 OPHTHALMIC US DX; QUANTITATIVE A-SCAN ONLY 76512 OPHTHALMIC US DX; B-SCAN W/WO NON-QUAN A-SCAN

76513 OPHTHALMIC US DX; ANT SEG US B- SCAN/BIOMICROSCPY 76514 OPHTHALMIC US DX; CORNEAL PACHYMETRY UNI/BIL 76516 OPHTHALMIC BIOMETRY ULTRASOUND ECHO A-SCAN; 76519 OPHTH BIOMETRY A-SCAN; W/IO LENS POWER CALCULAT 76529 OPHTHALMIC ULTRASONIC FOREIGN BODY LOCALIZATION 769 OTHER TREATMENT RM 770 PREVENT CARE SVS 771 VACCINE ADMIN 779 OTHER PREVENT 780 TELEMEDICINE 789 TELEMEDICINE/OTHER 790 LITHOTRIPSY 799 LITHOTRIPSY/OTHER 800 RENAL DIALYSIS 801 DIALY/INPT 802 DIALY/INPT/PER 803 DIALY/INPT/CAPD 804 DIALY/INPT/CCPD

809 DIALY/INPT/OTHER 810 ORGAN ACQUISIT 811 LIVING/DONOR 812 CADAVER/DONOR 813 UNKNOWN/DONOR 814 UNSUCCESSFUL SEARCH 819 OTHER/DONOR 820 HEMO/OP OR HOME 821 HEMO/COMPOSITE 822 HEMO/HOME/SUPPL 823 HEMO/HOME/EQUIP 824 HEMO/HOME/100% 825 HEMO/HOME/SUPSERV 829 HEMO/HOME/OTHER 830 PERITONEAL/OP OR HOME 831 PERTNL/COMPOSITE 832 PERTNL/HOME/SUPPL 833 PERTNL/HOME/EQUIP

834 PERTNL/HOME/100% 835 PERTNL/HOME/SUPSERV 839 PERTNL/HOME/OTHER 840 CAPD/OP OR HOME 841 CAPD/COMPOSITE 842 CAPD/HOME/SUPPL 843 CAPD/HOME/EQUIP 844 CAPD/HOME/100% 845 CAPD/HOME/SUPSERV 849 CAPD/HOME/OTHER 850 CCPD/OP OR HOME 851 CCPD/COMPOSITE 852 CCPD/HOME/SUPPL 853 CCPD/HOME/EQUIP 854 CCPD/HOME/100% 855 CCPD/HOME/SUPSERV 859 CCPD/HOME/OTHER 880 DIALY/MISC

881 DIALY/ULTRAFILT 882 HOME DIALYSIS AID VISIT 889 DIALY/MISC/OTHER 900 PSTAY TREATMENT 901 ELECTRO SHOCK 902 MILIEU THERAPY 903 PLAY THERAPY 904 ACTIVITY THERAPY 905 Intensive outpatient servicespsychiatric 906 INTENSIVE OUTPATIENT SERVICES- CHEMICAL DEPENDENCY 909 OTHER PSTAY RX 910 PSYCH/SERVICES 911 PSYCH/REHAB 912 PSYCH/PARTIAL HOSP 913 PSYCH/PARTIAL INSTENSIVE 914 PSYCH/INDIV RX 915 PSYCH/GROUP RX 916 PSYCH/FAMILY RX

917 PSYCH/BIOFEED 918 PSYCH/TESTING 919 PSYCH/OTHER 920 OTHER DX SVS 92002 OPHTH SERV: MED EXAM & EVAL; INTERMED NEW PT Exam Ophthalmology_KS 92002 OPHTH SERV: MED EXAM & EVAL; INTERMED NEW PT Exam Ophthalmology_KS 92002 OPHTH SERV: MED EXAM & EVAL; INTERMED NEW PT Exam_Vision_KS 92002 OPHTH SERV: MED EXAM & EVAL; INTERMED NEW PT Exam_Vision_KS 92004 OPHTH SERV: MED EXAM; COMP NEW PT 1/MORE VISITS Exam Ophthalmology_KS 92004 OPHTH SERV: MED EXAM; COMP NEW PT 1/MORE VISITS Exam Ophthalmology_KS 92004 OPHTH SERV: MED EXAM; COMP NEW PT 1/MORE VISITS Exam_Vision_KS 92004 OPHTH SERV: MED EXAM; COMP NEW PT 1/MORE VISITS Exam_Vision_KS 92012 OPHTH SERV: MED EXAM & EVAL; INITERMED ESTAB PT Exam Ophthalmology_KS 92012 OPHTH SERV: MED EXAM & EVAL; INITERMED ESTAB PT Exam Ophthalmology_KS 92012 OPHTH SERV: MED EXAM & EVAL; INITERMED ESTAB PT Exam_Vision_KS 92012 OPHTH SERV: MED EXAM & EVAL; INITERMED ESTAB PT Exam_Vision_KS 92014 OPHTH SERV: MED EXAM & EVAL; COMP ESTAB PT Exam Ophthalmology_KS 92014 OPHTH SERV: MED EXAM & EVAL; COMP ESTAB PT Exam Ophthalmology_KS

92014 OPHTH SERV: MED EXAM & EVAL; COMP ESTAB PT Exam_Vision_KS 92014 OPHTH SERV: MED EXAM & EVAL; COMP ESTAB PT Exam_Vision_KS 92015 DETERMINATION OF REFRACTIVE STATE Refraction_KS 92015 DETERMINATION OF REFRACTIVE STATE Refraction_KS 92018 OPHTH EXAM & EVAL-GEN ANES; CMPL 92019 OPHTH EXAM & EVAL-GEN ANES; LTD 92020 GONIOSCOPY Exam_Vision_KS 92020 GONIOSCOPY Exam_Vision_KS 92025 COMPUTERIZED CORNEAL TOPOGRAPHY UNI/BI Corneal Topography_KS 92060 SENSIMOTOR EXAM W/MX MSR OCULR DEV W/I&R-SP 92065 ORTHOPTIC &/ PLEOPTIC TRAIN W/MED DIRECT & EVAL 92070 FIT CNTC LENS TX DISEASE INCLUDING SUPPLY LENS 92071 FIT CONTACT LENS TX OCULAR SURFACE DISEASE 92081 VISUAL FIELD EXAM UNI/BIL W/I&R; LTD EXAM Visual Field Examination_KS 4 365 DAYS 92081 VISUAL FIELD EXAM UNI/BIL W/I&R; LTD EXAM Exam_Vision_KS 92081 VISUAL FIELD EXAM UNI/BIL W/I&R; LTD EXAM Exam_Vision_KS 92082 VISUAL FIELD EXAM UNI/BIL W/I&R; INTERMED Visual Field Examination_KS 4 365 DAYS 92082 VISUAL FIELD EXAM UNI/BIL W/I&R; INTERMED Exam_Vision_KS

92082 VISUAL FIELD EXAM UNI/BIL W/I&R; INTERMED Exam_Vision_KS 92083 VISUAL FIELD EXAM UNI/BIL W/I&R; EXTENDED EXAM Visual Field Examination_KS 4 365 DAYS 92083 VISUAL FIELD EXAM UNI/BIL W/I&R; EXTENDED EXAM Exam_Vision_KS 92083 VISUAL FIELD EXAM UNI/BIL W/I&R; EXTENDED EXAM Exam_Vision_KS 921 PERI VASCUL LAB 92100 SERIAL TONOMETRY-SEP PROC W/I&R SAME DAY Exam_Vision_KS 92100 SERIAL TONOMETRY-SEP PROC W/I&R SAME DAY Exam_Vision_KS 92120 TONOGRAPHY W/I&R-RECORD INDENTAT TONOMETER 92130 TONOGRAPHY WITH WATER PROVOCATION 92132 CMPTR OPHTHALMIC DX IMG ANT SEGMT W/I&R UNI/BI Exam_Vision_KS 92132 CMPTR OPHTHALMIC DX IMG ANT SEGMT W/I&R UNI/BI Exam_Vision_KS 92133 COMPUTERIZED OPHTHALMIC IMAGING OPTIC NERVE Exam_Vision_KS 92133 COMPUTERIZED OPHTHALMIC IMAGING OPTIC NERVE Exam_Vision_KS 92134 COMPUTERIZED OPHTHALMIC IMAGING RETINA Exam_Vision_KS 92134 COMPUTERIZED OPHTHALMIC IMAGING RETINA Exam_Vision_KS 92135 SCANNING CMPTIZED OPHTH DX IMAGING W/I&R UNI 92136 OPHTH BIOMETRY PART COHERENCE INTRFEROMETRY 92140 PROVOCATIVE TESTS GLAUC W/I&R WITHOUT TONOGRAPHY Exam_Vision_KS

92140 PROVOCATIVE TESTS GLAUC W/I&R WITHOUT TONOGRAPHY Exam_Vision_KS 922 EMG 92225 OPHTHALMOSCOPY EXT W/RETINAL DRAWING W/I&R; INIT 92226 OPHTH EXT W/RETINAL DRAWING W/I&R; SUBSEQUENT 92227 REMOTE IMG DX RETINL DIS W/ALYS & REPORT UNI/BI 92228 REMOTE IMG MGT RETINL DIS W/I&R UNI/BI 92230 FLUORESCEIN ANGIOSCOPY W/I&R 92235 FLUORESCEIN ANGIOGRAPHY W/I&R 92240 INDOCYANINE-GREEN ANGIOGRAPHY W/I&R 92250 FUNDUS PHOTOGRAPHY W/I&R 92260 OPHTHALMODYNAMOMETRY 92265 NEEDLE OCULOELECTROMYOGRAPHY 1/MORE MUSCL W/I&R 92270 ELECTRO-OCULOGRAPHY W/I&R 92275 ELECTRORETINOGRAPHY W/I&R 92283 COLOR VISION EXAM EXT EG ANOMALOSCOPE/EQUIVALENT 92284 DARK ADAPTATION EXAMINATION W/I&R 92285 EXT OCULR PHOTOGRAPHY W/I&R DOC MEDICAL PROGRESS 92286 SPEC ANT SEGMT PHOTO W/I&R; W/MICRO/CELL CNT

92287 SPCL ANT SEG PHOTGRPH W/I&R; W/FLUORESCEIN ANGIO 923 PAP SMEAR 92310 PRSC & FIT CONTACT LENS; CORNEAL EXCEPT APHAKIA Fitting_Ophthalmology_KS 92311 PRSC & FIT CONTACT LENS; CORNEAL-APHAKIA-1EYE Fitting_Ophthalmology_KS 92312 PRSC CONTACT LENS; CORNEAL- APHAKIA-BOTH EYES Fitting_Ophthalmology_KS 92313 PRSC & FIT CONTACT LENS; CORNEOSCLERAL LENS Fitting_Ophthalmology_KS 92316 PRSC W/FIT BY TECH; LENS- APHAKIA-BOTH EYES 92317 PRSC W/FIT BY TECH; CORNEOSCLERAL LENS 92325 MODIFICATION CNTC LENS W/MEDICAL SUPERVIS ADPT 92326 REPLACEMENT OF CONTACT LENS 92340 FITTING OF SPECTACLES EXCEPT APHAKIA; MONOFOCAL Fitting_Ophthalmology_KS 92340 FITTING OF SPECTACLES EXCEPT APHAKIA; MONOFOCAL Fitting_Vision_KS 92341 FITTING OF SPECTACLES EXCEPT APHAKIA; BIFOCAL Fitting_Ophthalmology_KS 92341 FITTING OF SPECTACLES EXCEPT APHAKIA; BIFOCAL Fitting_Vision_KS 92342 FIT SPECTACLES EX APHAKIA; MULTIFOCAL NOT BIFOCL Fitting_Ophthalmology_KS 92342 FIT SPECTACLES EX APHAKIA; MULTIFOCAL NOT BIFOCL Fitting_Vision_KS 92352 FITTING SPECTACLE PROSTHESIS APHAKIA; MONOFOCAL Fitting_Ophthalmology_KS 92352 FITTING SPECTACLE PROSTHESIS APHAKIA; MONOFOCAL Fitting_Vision_KS

92353 FITTING SPECTACLE PROSTHESIS APHAKIA; MULTIFOCAL Fitting_Ophthalmology_KS 92353 FITTING SPECTACLE PROSTHESIS APHAKIA; MULTIFOCAL Fitting_Vision_KS 92354 FIT SPECTACLE MOUNTED LOW VISION AID; 1 ELEM SYS Fitting_Ophthalmology_KS 92354 FIT SPECTACLE MOUNTED LOW VISION AID; 1 ELEM SYS Fitting_Vision_KS 92355 FIT SPECTACL MOUNT LO VISION AID; TELESCOP/OTHER Fitting_Ophthalmology_KS 92355 FIT SPECTACL MOUNT LO VISION AID; TELESCOP/OTHER Fitting_Vision_KS 92370 REPAIR AND REFITTING SPECTACLES; EXCEPT APHAKIA 92370 REPAIR AND REFITTING SPECTACLES; EXCEPT APHAKIA 92371 REPR&REFIT SPECTACLES; SPECTACLE PROSTH APHAKIA 924 ALLERGY TEST 925 PREG TEST 929 ADDITIONAL DX SVS 940 OTHER RX SVS 941 RECREATION RX 942 EDUC/TRAINING 943 CARDIAC REHAB 944 DRUG REHAB 945 ALCOHOL REHAB

946 RTN COMPLX MED EQUIP 947 COMPLX MED EQUIP 949 ADDITIONAL RX SVS 951 ATHLETIC TRAINING 95930 VISL EVOKED PTNTL TST CNTRL NRV SYS CHKRBD/FLASH 960 PRO FEE 961 PRO FEE/PSTAY 962 PRO FEE/EYE 963 PRO FEE/ANES MD 964 PRO FEE/ANES CRNA 969 OTHER PRO FEE 971 PRO FEE/LAB 972 PRO FEE/RAD/DX 973 PRO FEE/RAD/RX 974 PRO FEE/NUC MED 975 PRO FEE/OR 976 PRO FEE/RESPIR 977 PRO FEE/PHYSI

978 PRO FEE/OCUPA 979 PRO FEE/SPEECH 981 PRO FEE/ER 982 PRO FEE/OUTPT 983 PRO FEE/CLINIC 984 PRO FEE/SOC SVC 985 PRO FEE/EKG 986 PRO FEE/EEG 987 PRO FEE/HOS VIS 988 PRO FEE/CONSULT 989 FEE/PVT NURSE 990 PT CONVENIENCE 991 CAFETERIA 99173 SCREENING TEST VISUAL ACUITY QUANTITATIVE BIL Exam Ophthalmology_KS 99173 SCREENING TEST VISUAL ACUITY QUANTITATIVE BIL Exam Ophthalmology_KS 992 LINEN 99201 OFFICE OUTPT NEW 10 MIN 99202 OFFICE OUTPT NEW 20 MINUTES

99203 OFFICE OUTPT NEW 30 MIN 99204 OFFICE OUTPT NEW 45 MIN 99205 OFFICE OUTPT NEW 60 MIN 99211 OFC/OUTPT VISIT E&M ESTAB NO PHYS PRES 5 MIN 99212 OFC/OUTPT VISIT E&M EST SELF- LIMIT/MINOR 10 MIN 99213 OFC/OUTPT VISIT E&M EST LOW- MOD SEVERITY 15 MIN 99214 OFC/OUTPT VISIT E&M EST MOD-HI SEVERITY 25 MIN 99215 OFC/OUTPT VISIT E&M ESTAB MOD- HI SEVRTY 40 MIN 99217 OBSERVATION CARE DISCHARGE DAY MANAGEMENT 99218 INIT OBSRV CARE-DAY E&M LOW SEVERITY 99219 INIT OBSRV CARE-DAY E&M MODERATE SEVERITY 99220 INIT OBSRV CARE-DAY E&M HIGH SEVERITY 99221 1ST HOSP CARE PR D 30 MIN 99222 INIT HOSP CARE-DAY E&M MODERATE SEVERITY 50 MIN 99223 INIT HOSP CARE-DAY E&M HIGH SEVERITY 70 MIN 99224 SBSQ OBS CARE PR D LOW SEVERITY 99225 SBSQ OBS CARE PR D MODERATE SEVERITY 99226 SBSQ OBS CARE PR D HIGH SEVERITY

99231 SUBSQT HOSP CARE-DAY E&M STABLE/RECOVER 15 MIN 99232 SUBSQT HOSP CARE-DAY E&M MINOR CMPL 25 MIN 99233 SUBSQT HOSP CARE-DAY E&M SIGNIFIC CMPL 35 MIN 99234 OBSRV/INPT HOSP CARE E&M LOW SEVERITY 99235 OBSRV/INPT HOSP CARE E&M MODERATE SEVERITY 99236 OBSRV/INPT HOSP CARE E&M HIGH SEVERITY 99238 HOSPITAL D/C DAY MANAGEMENT; 30 MINUTES/LESS 99239 HOSPITAL DISCHARGE DAY MANAGEMENT; > 30 MINUTES 99241 OFFICE CNSLT NEW/ESTAB SELF LIMIT/MINOR 15 MIN 99242 OFFICE CNSLT NEW/ESTAB LOW SEVERITY 30 MIN 99243 OFFICE CNSLT NEW/ESTAB MODERATE SEVERITY 40 MIN 99244 OFFICE CNSLT NEW/ESTAB MOD- HIGH SEVERITY 60 MIN 99245 OFFICE CNSLT NEW/ESTAB MOD- HIGH SEVERITY 80 MIN 99251 INIT INPT CNSLT NEW/EST SELF LIMIT/MINOR 20 MIN 99252 INIT INPT CNSLT NEW/ESTAB LOW SEVERITY 40 MIN 99253 INIT INPT CNSLT NEW/EST MODERATE SEVERITY 55MIN 99254 1ST INPT CONSLTJ 80 MIN 99255 INIT INPT CNSLT NEW/EST MOD-HI SEVERITY 110 MIN

99281 EMERG DEPT VISIT E&M SELF LIMITED/MINOR 99282 EMERG DEPT VISIT E&M LOW- MODERATE SEVERITY 99283 EMERG DEPT VISIT E&M MODERATE SEVERITY 99284 EMERG DEPT VISIT E&M HIGH SEVERITY URGENT EVAL 99285 EMERG DEPT E&M-HIGH SEVERITY IMMED SIG THREAT 993 TELEPHONE 994 TV/RADIO 995 NONPT ROOM RENT 996 LATE DISCHARGE 997 ADMIT KITS 998 BARBER/BEAUTY 999 PT CONVENCE/OTH J0585 BOTULINUM TOXIN TYPE A PER UNIT 800 DAYS J2503 INJECTION PEGAPTANIB SODIUM 0.3 MG 4 DAYS J2778 INJECTION RANIBIZUMAB 0.1 MG 10 DAYS J3300 INJ TRIAMCINOLONE ACETONIDE PRES FREE 1 MG 240 DAYS J3301 INJECTION TRIAMCINOLONE ACETONIDE PER 10 MG 16 DAYS J3396 INJECTION VERTEPORFIN 0.1 MG 300 DAYS

J7312 INJECTION DEXAMETHASONE INTRAVITREAL IMPL 0.1 MG 14 DAYS J9035 INJECTION BEVACIZUMAB 10 MG 400 DAYS L8610 OCULAR IMPLANT L8612 AQUEOUS SHUNT Q2046 INJECTION AFLIBERCEPT 1 MG 4 DAYS S0500 DISPOSABLE CONTACT LENS PER LENS S0580 POLYCARBONATE LENS S0580 POLYCARBONATE LENS S0620 ROUTINE OPHTH EXAM INCL REFRACTION; NEW PT V2020 FRAMES PURCHASES V2020 FRAMES PURCHASES V2025 DELUXE FRAME V2100 SPHERE SINGLE VISION PLANO +/- 4.00 PER LENS V2101 SPHERE SINGLE VISION +/- 4.12 +/- 7.00D PER LENS V2101 SPHERE SINGLE VISION +/- 4.12 +/- 7.00D PER LENS V2102 SPHERE SINGLE VISN +/- 7.12 +/- 20.00D PER LENS V2102 SPHERE SINGLE VISN +/- 7.12 +/- 20.00D PER LENS V2103 1 VISN PLANO TO+/-4.00D SPHER 0.12-2.00D CYL EA

V2103 1 VISN PLANO TO+/-4.00D SPHER 0.12-2.00D CYL EA V2104 1 VISN PLANO-+/- 4.00D SPHER 2.12-4.00D CYL EA V2104 1 VISN PLANO-+/- 4.00D SPHER 2.12-4.00D CYL EA V2105 1 VISN PLANO-+/- 4.00D SPHER 4.25-6.00D CYL EA V2105 1 VISN PLANO-+/- 4.00D SPHER 4.25-6.00D CYL EA V2106 1 VISN PLANO-+/- 4.00D SPHER OVER 6.00D CYL-LENS V2106 1 VISN PLANO-+/- 4.00D SPHER OVER 6.00D CYL-LENS V2107 1 VISN +/- 4.25-+/ 7.00 SPHER 0.12-2.00D CYL EA V2107 1 VISN +/- 4.25-+/ 7.00 SPHER 0.12-2.00D CYL EA V2108 1 VISN +/-4.25D-+/-7.00D SPHER 2.12-4.00D CYL EA V2108 1 VISN +/-4.25D-+/-7.00D SPHER 2.12-4.00D CYL EA V2109 1 VISN+/- 4.25-+/- 7.00D SPHER 4.25-6.00D CYL EA V2109 1 VISN+/- 4.25-+/- 7.00D SPHER 4.25-6.00D CYL EA V2110 1 VISN +/- 4.25-7.00D SPHERE OVER 6.00D CYL EA V2110 1 VISN +/- 4.25-7.00D SPHERE OVER 6.00D CYL EA V2111 1 VISN +/-7.25-+/-12.00D SPHER 0.25-2.25D CYL EA V2111 1 VISN +/-7.25-+/-12.00D SPHER 0.25-2.25D CYL EA V2112 1 VISN +/- 7.25 +/- 12.00D SPH 2.25D-400D CYL EA

V2112 1 VISN +/- 7.25 +/- 12.00D SPH 2.25D-400D CYL EA V2113 1 VISN +/- 7.25 +/- 12.00D SPH 4.25-6.00D CYL EA V2113 1 VISN +/- 7.25 +/- 12.00D SPH 4.25-6.00D CYL EA V2114 SINGLE VISION SPHERE OVER +/- 12.00D PER LENS V2114 SINGLE VISION SPHERE OVER +/- 12.00D PER LENS V2115 LENTICULAR PER LENS SINGLE VISION V2115 LENTICULAR PER LENS SINGLE VISION V2118 ANISEIKONIC LENS SINGLE VISION V2118 ANISEIKONIC LENS SINGLE VISION V2121 LENTICULAR LENS PER LENS SINGLE V2121 LENTICULAR LENS PER LENS SINGLE V2199 NOT OTHERWISE CLASSIFIED SINGLE VISION LENS V2199 NOT OTHERWISE CLASSIFIED SINGLE VISION LENS V2200 SPHERE BIFOCL PLANO TO PLUS/MINUS 4.00D PER LENS V2200 SPHERE BIFOCL PLANO TO PLUS/MINUS 4.00D PER LENS V2201 SPHERE BIFOCAL +/- 4.12 TO +/- 7.00D PER LENS V2201 SPHERE BIFOCAL +/- 4.12 TO +/- 7.00D PER LENS V2202 SPHERE BIFOCL +/- 7.12 TO +/- 20.00D PER LENS

V2202 SPHERE BIFOCL +/- 7.12 TO +/- 20.00D PER LENS V2203 BIFOCL PLANO +/- 4.00D SPHER 0.12-2.00D CYL-EA V2203 BIFOCL PLANO +/- 4.00D SPHER 0.12-2.00D CYL-EA V2204 BIFOCL PLANO +/- 4.00D SPHER 2.12-4.00D CYL-EA V2204 BIFOCL PLANO +/- 4.00D SPHER 2.12-4.00D CYL-EA V2205 BIFOCL PLANO +/- 4.00D SPHER 4.25-6.00D CYL-EA V2205 BIFOCL PLANO +/- 4.00D SPHER 4.25-6.00D CYL-EA V2206 BIFOCL PLANO +/- 4.00D SPHER OVR 6.00D CYL-EA V2206 BIFOCL PLANO +/- 4.00D SPHER OVR 6.00D CYL-EA V2207 BIFOCL +/-4.25-+/-7.00D SPHER 0.12-2.00D CYL-EA V2207 BIFOCL +/-4.25-+/-7.00D SPHER 0.12-2.00D CYL-EA V2208 BIFOCL +/-4.25-+/-7.00D SPHER 2.12-4.00D CYL-EA V2208 BIFOCL +/-4.25-+/-7.00D SPHER 2.12-4.00D CYL-EA V2209 BIFOCL +/-4.25-+/-7.00D SPHER 4.25-6.00D CYL-EA V2209 BIFOCL +/-4.25-+/-7.00D SPHER 4.25-6.00D CYL-EA V2210 BIFOCL +/-4.25-+/-7.00D SPHER OVR 6.00D CYL-LENS V2210 BIFOCL +/-4.25-+/-7.00D SPHER OVR 6.00D CYL-LENS V2211 BIFOCL +/-7.25-+/-12.00D SPHER 0.25-2.25D CYL-EA

V2211 BIFOCL +/-7.25-+/-12.00D SPHER 0.25-2.25D CYL-EA V2212 BIFOCL +/-7.25-+/-12.00D SPHER 2.25-4.00D CYL-EA V2212 BIFOCL +/-7.25-+/-12.00D SPHER 2.25-4.00D CYL-EA V2213 BIFOCL +/-7.25-+/-12.00D SPHER 4.25-6.00D CYL-EA V2213 BIFOCL +/-7.25-+/-12.00D SPHER 4.25-6.00D CYL-EA V2214 BIFOCAL SPHERE OVER +/-12.00D PER LENS V2214 BIFOCAL SPHERE OVER +/-12.00D PER LENS V2215 LENTICULAR PER LENS BIFOCAL V2215 LENTICULAR PER LENS BIFOCAL V2218 ANISEIKONIC PER LENS BIFOCAL V2218 ANISEIKONIC PER LENS BIFOCAL V2219 BIFOCAL SEG WIDTH OVER 28MM V2219 BIFOCAL SEG WIDTH OVER 28MM V2220 BIFOCAL ADD OVER 3.25D V2220 BIFOCAL ADD OVER 3.25D V2221 LENTICULAR LENS PER LENS BIFOCAL V2221 LENTICULAR LENS PER LENS BIFOCAL V2299 SPECIALTY BIFOCAL

V2300 SPHERE TRIFOCAL PLANO OR +/- 4.00D PER LENS V2300 SPHERE TRIFOCAL PLANO OR +/- 4.00D PER LENS V2301 SPHERE TRIFOCAL +/- 4.12 TO +/- 7.00D PER LENS V2301 SPHERE TRIFOCAL +/- 4.12 TO +/- 7.00D PER LENS V2302 SPHERE TRIFOCAL +/- 7.12 TO +/- 20.00 PER LENS V2302 SPHERE TRIFOCAL +/- 7.12 TO +/- 20.00 PER LENS V2303 TRIFOCL PLANO +/-4.00D SPHER 0.12-2.00D CYL EA V2303 TRIFOCL PLANO +/-4.00D SPHER 0.12-2.00D CYL EA V2304 TRIFOCL PLANO +/-4.00D SPHER 2.25-4.00D CYL EA V2304 TRIFOCL PLANO +/-4.00D SPHER 2.25-4.00D CYL EA V2305 TRIFOCL PLANO +/-4.00D SPHER 4.25-6.00 CYL EA V2305 TRIFOCL PLANO +/-4.00D SPHER 4.25-6.00 CYL EA V2306 TRIFOCL PLANO +/-4.00D SPHER OVR 6.00D CYL EA V2306 TRIFOCL PLANO +/-4.00D SPHER OVR 6.00D CYL EA V2307 TRIFOCL +/-4.25-+/-7.00D SPHER 0.12-2.00D CYL EA V2307 TRIFOCL +/-4.25-+/-7.00D SPHER 0.12-2.00D CYL EA V2308 TRIFOCL +/-4.25-+/-7.00D SPHER 2.12-4.00D CYL EA V2308 TRIFOCL +/-4.25-+/-7.00D SPHER 2.12-4.00D CYL EA

V2309 TRIFOCL +/-4.25-+/-7.00D SPHER 4.25-6.00D CYL EA V2309 TRIFOCL +/-4.25-+/-7.00D SPHER 4.25-6.00D CYL EA V2310 TRIFOCL +/-4.25-+/-7.00D SPHER OVR 6.00D CYL EA V2310 TRIFOCL +/-4.25-+/-7.00D SPHER OVR 6.00D CYL EA V2311 TRIFOCL +/-7.25-+/-12.00D SPHER 0.25-2.25D CYL E V2311 TRIFOCL +/-7.25-+/-12.00D SPHER 0.25-2.25D CYL E V2312 TRIFOCL +/-7.25-+/-12.00D SPHER 2.25-4.00D CYL E V2312 TRIFOCL +/-7.25-+/-12.00D SPHER 2.25-4.00D CYL E V2313 TRIFOCL+/-7.25-+/-12.00D SPHER 4.25-6.00D CYL EA V2313 TRIFOCL+/-7.25-+/-12.00D SPHER 4.25-6.00D CYL EA V2314 TRIFOCL SPHER OVER +/-12.00D PER LENS V2314 TRIFOCL SPHER OVER +/-12.00D PER LENS V2315 LENTICULAR PER LENS TRIFOCAL V2315 LENTICULAR PER LENS TRIFOCAL V2318 ANISEIKONIC LENS TRIFOCAL V2318 ANISEIKONIC LENS TRIFOCAL V2319 TRIFOCAL SEG WIDTH OVER 28 MM V2319 TRIFOCAL SEG WIDTH OVER 28 MM

V2320 TRIFOCAL ADD OVER 3.25D V2320 TRIFOCAL ADD OVER 3.25D V2321 LENTICULAR LENS PER LENS TRIFOCAL V2321 LENTICULAR LENS PER LENS TRIFOCAL V2399 SPECIALTY TRIFOCAL V2399 SPECIALTY TRIFOCAL V2410 VARIBL ASPHRCTY LENS 1 FULL FLD GLASS/PLASTC LNS V2410 VARIBL ASPHRCTY LENS 1 FULL FLD GLASS/PLASTC LNS V2430 VARIBL ASPHRCITY LENS BIFOCL FULL FIELD-LENS V2430 VARIBL ASPHRCITY LENS BIFOCL FULL FIELD-LENS V2499 VARIABLE SPHERICITY LENS OTHER TYPE V2499 VARIABLE SPHERICITY LENS OTHER TYPE V2500 CONTACT LENS PMMA SPHERICAL PER LENS V2501 CONTACT LENS PMMA TORIC/PRISM BALLAST PER LENS V2502 CONTACT LENS PMMA BIFOCAL PER LENS V2503 CONTACT LENS PMMA COLOR VISION DEFIC PER LENS V2510 CONTACT LENS GAS PERMEABLE SPHERICAL PER LENS V2511 CNTC LENS GAS PERMEABLE TORIC PRISM BALLST-LENS

V2512 CONTACT LENS GAS PERMEABLE BIFOCAL PER LENS V2513 CNTC LENS GAS PERMEABLE EXTENDED WEAR PER LENS V2520 CONTACT LENS HYDROPHILIC SPHERICAL PER LENS V2521 CNTC LENS HYDROPHIL TORIC/PRISM BALLST PER LENS V2522 CONTACT LENS HYDROPHILIC BIFOCAL PER LENS V2523 CONTACT LENS HYDROPHILIC EXTENDED WEAR PER LENS V2530 CONTACT LENS SCLERAL GAS IMPERMEABLE PER LENS V2531 CONTACT LENS SCLERAL GAS PERMEABLE PER LENS V2623 PROSTHETIC EYE PLASTIC CUSTOM V2624 POLISHING/RESURFACING OF OCULAR PROSTHESIS V2625 ENLARGEMENT OF OCULAR PROSTHESIS V2626 REDUCTION OF OCULAR PROSTHESIS V2627 SCLERAL COVER SHELL V2628 FABRICATION AND FITTING OF OCULAR CONFORMER V2629 PROSTHETIC EYE OTHER TYPE V2630 ANTERIOR CHAMBER INTRAOCULAR LENS V2631 IRIS SUPPORTED INTRAOCULAR LENS V2632 POSTERIOR CHAMBER INTRAOCULAR LENS

V2702 DELUXE LENS FEATURE V2710 SLAB OFF PRISM GLASS OR PLASTIC PER LENS V2710 SLAB OFF PRISM GLASS OR PLASTIC PER LENS V2715 PRISM PER LENS V2715 PRISM PER LENS V2718 PRESS-ON LENS FRESNELL PRISM PER LENS V2730 SPECIAL BASE CURVE GLASS OR PLASTIC PER LENS V2740 Tint, plastic, rose 1 or 2 per lens V2741 Tint, plastic, other than rose 1-2, per lens V2742 Tint, glass rose 1 or 2, per lens V2743 Tint, glass other than rose 1 or 2, per lens V2744 TINT PHOTOCHROMATIC PER LENS V2745 ADD LENS; TINT COLOR SOLID EXCLD PHOTOCHRMATC V2750 ANTIREFLECTIVE COATING PER LENS V2755 U-V LENS PER LENS V2756 EYE GLASS CASE V2760 SCRATCH RESISTANT COATING PER LENS V2760 SCRATCH RESISTANT COATING PER LENS

V2761 MIRROR COAT TYPE SOLID GRADENT/= LENS MATL-LENS V2762 POLARIZATION ANY LENS MATERIAL PER LENS V2770 OCCLUDER LENS PER LENS V2780 OVERSIZE LENS PER LENS V2781 PROGRESSIVE LENS PER LENS V2782 LENS INDX 1.54-1.65 PLSTC/1.60-1.79 GLASS LENS V2782 LENS INDX 1.54-1.65 PLSTC/1.60-1.79 GLASS LENS V2783 LENS INDX >/= 1.66 PLSTC/>/= 1.80 GLASS LENS V2783 LENS INDX >/= 1.66 PLSTC/>/= 1.80 GLASS LENS V2784 LENS POLYCARBONATE OR EQUAL ANY INDEX PER LENS Polycarbonate Lenses_KS V2784 LENS POLYCARBONATE OR EQUAL ANY INDEX PER LENS Polycarbonate Lenses_KS V2785 PROCESSING PRES&TRANSPORTING CORNEAL TISSUE V2786 SPECIALTY OCCUPATIONAL MULTIFOCAL LENS PER LENS V2787 ASTIGMATISM CORRECTING FUNCTION INTRAOCULAR LENS V2788 PRESBYOPIA CORRECTION FUNCTION INTRAOCULAR LENS V2790 AMNIOTIC MEMBRANE SURGICAL RECONSTRUCT PER PROC V2797 VISN SPL ACSS &/ SRVC CMPNT ANOTHER HCPCS CODE V2799 VISION SERVICE MISCELLANEOUS

V2799 VISION SERVICE MISCELLANEOUS V5120 BINAURAL BODY

OFFICE VISIT Authorization Request Form FAX ALL REQUESTS TO: 1-800-310-9871 Member Information: Member: DOB: Member ID #: Health Plan: Physician Information: Physician: Contact: Phone #: Fax #: Appointment Information: Today s Date: Appointment Date: Referring Physician: Last Examine Date: By: Diagnosis: CPT Codes: ICD-9 Code: Treatment Plan or Procedure (if applicable): Number of Visits Requested: _1 Ocular nefits CONFIDENTIAL Provider Manual 158

Member: DOB: Member ID #: Health Plan: Physician: Contact: Phone #: Fax #: Treatment or Procedure (CPT & Description): OD Diagnosis (ICD-9 & Description): Treatment Location: Inpatient Outpatient Tentative Surgery Date: INFORMATION FOR ALL CASES: Legible, complete copies of the last 3 chart notes, if available Medical / Surgical Review Form FAX ALL REQUESTS TO: 1-800-310-9871 For Cataract and YAG Laser Surgeries: 1. PAM, OU 2. st corrected VA, OU 3. Glare Test, OU (if nec.) 4. VA with correction, OU For Plastic and Reconstructive Surgeries: 1. Copies of visual fields (taped and untaped) 2. Copies of external ocular photos OS MEMBER INFORMATION: Plan : OCULAR BENEFITS USE ONLY DO NOT WRITE BELOW THIS LINE Plan Code: REVIEW DETERMINATION: 1. Criteria: 2. Authorized Procedure: 3. Denial Reason: Uncovered Services Services did not meet medical necessity requirements 4. of Denial: Non-Urgent Urgent Concurrent Retrospective Emergent 5. If Denial Referring provider was contacted and offered an opportunity to discuss the denial 6. Professional Authorization #: Expires: Co-Pay:$ 7. Facility Authorization #: Expires: Co-Pay:$ 8. Anesthesia Authorization #: Expires: Co-Pay:$ 1 st Reviewer: 2 nd Reviewer: Review Process Date Time N/A Initial request Request for additional information if necessary Receipt of additional medical information if requested Peer to peer review offered Request sent to Medical Director for determination Medical Director s decision* Sent to HMO s Medical Director for final determination* Receipt of HMO s Medical Director s decision* Denial letter sent to member PCP notified of denial by phone or fax Provider notified of denial by fax or letter *Not necessary for benefit denial Action taken of non-deliverable to member: Authorization Faxed on: (Fax confirmation attached) Ocular nefits CONFIDENTIAL Provider Manual 159