Commonwealth of Massachusetts Subchapter Number and Title Page MassHealth 6. Service Codes 6-12 Provider Manual Series Transmittal Letter Date Vision Care Manual VIS-40 01/01/12 MISCELLANEOUS OCULARISTS, OPHTHALMOLOGISTS, OPTICIANS, AND – OPTOMETRISTS 99173 Screening test of visual acuity, quantitative, bilateral (use for titmus vision test) T2002 Nonemergency transportation, per diem (once per member per date of service for each member for whom the provider delivered or picked up eyeglasses, or to whom vision care services were provided out of the office) V2799 Vision service, miscellaneous (PA) (IC) MISCELLANEOUS OPHTHALMOLOGISTS, OPTICIANS, AND OPTOMETRISTS ONLY – V2600 Hand-held low-vision aids and other nonspectacle-mounted aids (PA) (IC) V2610 Single-lens spectacle-mounted low-vision aids (PA) (IC) V2615 Telescopic and other compound lens system, including distance vision telescopic, near vision telescopes, and compound microscopic lens system (PA) (IC) MISCELLANEOUS OCULARISTS ONLY – V2623 Prosthetic eye, plastic, custom (IC) V2624 Polishing/resurfacing of ocular prosthesis (IC) V2625 Enlargement of ocular prosthesis (IC) V2626 Reduction of ocular prosthesis (IC) V2627 Scleral cover shell (IC) V2628 Fabrication and fitting of ocular conformer (IC) V2629 Prosthetic eye, other type (PA) (IC)
Commonwealth of Massachusetts MassHealth Provider Manual Series Vision Care Manual Subchapter Number and Title 6. Service Codes Page 6-12 Transmittal Letter VIS-40 Date 01/01/12 MISCELLANEOUS – OCULARISTS, OPHTHALMOLOGISTS, OPTICIANS, AND OPTOMETRISTS 99173 Screening test of visual acuity, quantitative, bilateral (use for titmus vision test) T2002 Nonemergency transportation, per diem (once per member per date of service for each member for whom the provider delivered or picked up eyeglasses, or to whom vision care services were provided out of the office) V2799 Vision service, miscellaneous (PA) (IC) MISCELLANEOUS – OPHTHALMOLOGISTS, OPTICIANS, AND OPTOMETRISTS ONLY V2600 Hand-held low-vision aids and other nonspectacle-mounted aids (PA) (IC) V2610 Single-lens spectacle-mounted low-vision aids (PA) (IC) V2615 Telescopic and other compound lens system, including distance vision telescopic, near vision telescopes, and compound microscopic lens system (PA) (IC) MISCELLANEOUS – OCULARISTS ONLY V2623 Prosthetic eye, plastic, custom (IC) V2624 Polishing/resurfacing of ocular prosthesis (IC) V2625 Enlargement of ocular prosthesis (IC) V2626 Reduction of ocular prosthesis (IC) V2627 Scleral cover shell (IC) V2628 Fabrication and fitting of ocular conformer (IC) V2629 Prosthetic eye, other type (PA) (IC)
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