Rates for Vision Care Services and Ophthalmic Materials

Final Adoption Date Published in the Mass Register: February 14, 2025

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 315.00: RATES FOR VISION CARE SERVICES AND OPHTHALMIC MATERIALS

Section .01: General Provisions .02: General Definitions .03: General Rate Provisions .04: Allowable Fees for Vision Care Services .05: Severability

315.01: General Provisions

(1) Scope. .00 governs the rates of payment used by governmental units and purchasers under M.G.L. c. 152, § 1 et seq. (the Workers’ Compensation Act) for vision care services and ophthalmic materials provided to publicly aided and industrial accident patients.

(2) Applicable Dates of Service. Rates contained in .00 are effective for dates of service on or after February 14, 2025.

(3) Disclaimer of Authorization of Services. .00 is not authorization for or approval of the procedures for which rates are determined pursuant to .00. Governmental units that purchase care are responsible for the definition, authorization, and approval of care and services provided to publicly aided clients.

(4) Administrative Bulletins. EOHHS may issue administrative bulletins to clarify provisions of .00, or to issue coding updates and corrections under .01(5).

(5) Coding Updates and Corrections. EOHHS may publish service code updates and corrections in the form of administrative bulletin. Updates may reference coding systems including, but not limited to, the American Medical Association’s Current Procedural Terminology (CPT) and the Healthcare Common Procedure Coding System (HCPCS). The publication of such updates and corrections will list (a) codes for which the code numbers change, with the corresponding cross references between the new codes and the codes being replaced. Rates for such updated codes are set at the rate of the code that is being replaced; (b) codes for which the code numbers remain the same but the description has changed; (c) deleted codes for which there are no corresponding new codes; and (d) codes for entirely new services that require pricing. EOHHS will list these codes and apply individual consideration (IC) payment for these codes until appropriate rates can be developed.

315.02: General Definitions

The terms used in .00 shall have the meanings ascribed in .02 and in the CPT Coding Handbook. The descriptions and five-digit procedure codes included in .00 are obtained from the American Medical Association’s Current Procedural Terminology (CPT), copyright 2024, or the 2024 Healthcare Common Procedure Coding System Level II (HCPCS) unless otherwise specified. Both sources provide a listing of descriptive terms 1

Final Adoption Date Published in the Mass Register: February 14, 2025

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

.00: RATES FOR VISION CARE SERVICES AND OPHTHALMIC MATERIALS

and alpha-numeric identifying codes and modifiers for reporting medical services and procedures performed by health care providers.

Consultation. A type of service provided by a physician or ophthalmologist or optometrist whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or ophthalmologist or optometrist or other appropriate source. A physician consultant may initiate diagnostic and/or therapeutic services. The request for a consultation from the attending physician or ophthalmologist or optometrist or other appropriate source and the need for consultation must be documented in the patient's medical record. The consultant's opinion and any services that were ordered or performed must also be documented in the patient's medical record and communicated to the requesting physician or other appropriate source. Any specifically identifiable procedure (i.e., identified with a specific CPT code) performed on or subsequent to the date of the initial consultation should be reported separately. If a consultant subsequently assumes responsibility for management of a portion or all of the patient's condition(s), the consultation codes should not be used.

Eligible Provider (Provider). Ophthalmologists, optometrists, and dispensing opticians who are registered by an appropriate board of registration in accordance with the provision of M.G.L. c. 112; are not under contractual arrangement with a hospital or affiliated teaching institution for professional services; and who also meet such conditions of participation as may be required by a governmental unit purchasing vision care services and ophthalmic materials or by purchasers under M.G.L. c. 152.

EOHHS. The Executive Office of Health and Human Services established under M.G.L. c. 6A.

Established Patient. A patient who has received professional services from the physician or ophthalmologist or optometrist within the past three years.

Governmental Unit. The Commonwealth, any department, agency, board, or commission of the Commonwealth, and any political subdivision of the Commonwealth.

Individual Consideration (IC). For service codes for which no rate is listed, the purchaser determines the payment amount on an individual consideration basis upon receipt of a bill that describes the services rendered. The purchaser shall determine the appropriate payment in accordance with the following criteria: (a) time required to perform the procedure; (b) degree of skill required for the procedure rendered; (c) severity and complexity of the patient's disorder or disability; (d) cost of goods supplied in rendering the service, including catalogue prices of major supplies; and (e) policies, procedures, and practices of other third-party purchasers of care, governmental and private.

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Final Adoption Date Published in the Mass Register: February 14, 2025

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

.00: RATES FOR VISION CARE SERVICES AND OPHTHALMIC MATERIALS

Low Vision. Any pathological, traumatic, or congenital condition of the eye or brain that results in reduced visual acuity or reduction of visual field, and that is not amenable to medical, surgical, or ordinary optical correction.

Low-vision Aids. Items including, but not limited to, microscopic and telescopic lenses to correct low vision.

Low-vision Evaluation. A series of evaluative vision tests to measure the degree of low vision and the corrective lenses or aids required.

Modifiers. Listed services may be modified under certain circumstances. When applicable, the modifying circumstances should be identified by the addition of the appropriate two-digit number or letters placed after the usual procedure number from which it is separated by a hyphen.

New Patient. A patient who has not received any professional services from the physician or ophthalmologist or optometrist within the past three years.

Ocular Prosthetic Services. The dispensing and adjustment of false eyes.

Publicly Aided Individual. A person for whose medical and other services a governmental unit is in whole or in part liable under a statutory program.

Vision-care Services and Ophthalmic Materials. Professional care of the eye for the purpose of diagnosing and correcting refractive errors and includes the measurement, specification, formulation, construction, and dispensing of eyeglasses and related eye-care appliances.

315.03: General Rate Provisions

(1) Rate Determination. The rates for authorized vision care services and ophthalmic materials under .00 are the lower of (a) the provider’s usual fee to patients other than publicly aided or industrial accident patients; or (b) the schedule of allowable fees set forth in .04. (2) Reimbursement as Full Payment. The rates established by .00 are full compensation for vision services provided to publicly aided and industrial-accident patients as well as for any related administrative or supervisory duties in connection with the provision of vision care services without regard to where the services are provided. (3) Bulk Purchase Contract. If the provider is required by the purchasing governmental unit to order material from designated suppliers under a bulk purchase contract, the provider shall bill the purchasing agency only for the relevant dispensing fee.

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Final Adoption Date Published in the Mass Register: February 14, 2025

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

.00: RATES FOR VISION CARE SERVICES AND OPHTHALMIC MATERIALS

315.04: Allowable Fees for Vision Care Services

(1) Modifiers. The following modifiers are used to adjust payments under the circumstances noted in .04(1)(a) and (b). (a) -52 Reduced Services. Modifier -52 is used to describe circumstances in which services provided were reduced in comparison to the full description of the service. When a provider does not complete a procedure in its entirety, such as a provider electing to partially reduce or eliminate a service, the procedure must be billed by appending modifier -52 to the service code. The rate for services billed with modifier -52 is 86% of the rate listed in 101 CMR 315.04(2). For example, modifier -52 would be used for a procedure that includes administration of eyedrops when an optometrist who is not certified to distribute eyedrops, performs the procedure. (b) Provider Preventable Conditions. The following modifiers are used to report provider preventable conditions in accordance with 42 CFR. 447.26 and result in nonpayment for services.

Modifier Description PA Surgical or other invasive procedure performed on the wrong body part PB Surgical or other invasive procedure performed on the wrong patient PC Wrong surgical or other invasive procedure performed on a patient

(2) Services and Payments Covered Under Other Regulations. Payments for some services performed by ophthalmologists are governed by other EOHHS regulations, including 101 CMR 316.00: Rates for Surgery and Anesthesia Services; and 101 CMR 317.00: Rates for Medicine Services. The following codes are included in 101 CMR 316.00: 65210, 65222, 67820, 67938, 68761, 68801, and 68840. The following codes are included in 101 CMR 317.00: 92132, 92133, 92134, 92201, 92202, 92227, 92228, 92250, 92273, 92274, 99174, and 99177.

Procedure Rate Description Code Ophthalmic ultrasound, diagnostic; B-scan (with or without 76512 $103.11 superimposed non-quantitative A-scan) Ophthalmic ultrasound, diagnostic; anterior segment ultrasound, 76513 $103.11 immersion (water bath) B-scan or high resolution biomicroscopy, unilateral or bilateral Ophthalmic ultrasound, diagnostic; corneal pachymetry, 76514 $9.56 unilateral or bilateral (determination of corneal thickness) Ophthalmological services: medical examination and evaluation 92002 $57.88 with initiation of diagnostic and treatment program; intermediate, new patient

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Final Adoption Date Published in the Mass Register: February 14, 2025

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

.00: RATES FOR VISION CARE SERVICES AND OPHTHALMIC MATERIALS

Procedure Rate Description Code Ophthalmological services: medical examination and evaluation 92004 $74.91 with initiation of diagnostic and treatment program; comprehensive, new patient, 1 or more visits Ophthalmological services: medical examination and evaluation, 92012 $48.47 with initiation or continuation of diagnostic and treatment program; intermediate, established patient Ophthalmological services: medical examination and evaluation, 92014 $55.08 with initiation or continuation of diagnostic and treatment program; comprehensive, established patient, 1 or more visits 92015 $13.78 Determination of refractive state 92020 $22.07 Gonioscopy (separate procedure) Orthoptic training; performed by a physician or other qualified 92065 $30.13 health care professional Visual field examination, unilateral or bilateral, with interpretation and report; limited examination (eg, tangent 92081 $23.29 screen, Autoplot, arc perimeter, or single stimulus level automated test, such as Octopus 3 or 7 equivalent) Visual field examination, unilateral or bilateral, with interpretation and report; intermediate examination (eg, at least 2 92082 $61.33 isopters on Goldmann perimeter, or semiquantitative, automated suprathreshold screening program, Humphrey suprathreshold automatic diagnostic test, Octopus program 33) Visual field examination, unilateral or bilateral, with interpretation and report; extended examination (eg, Goldmann visual fields with at least 3 isopters plotted and static 92083 $90.11 determination within the central 30 degrees or quantitative, automated threshold perimetry, Octopus program G-1, 32 or 42, Humphrey visual field analyzer full threshold programs 30-2, 24- 2, or 30/60-2) Serial tonometry (separate procedure) with multiple measurements of intraocular pressure over an extended time 92100 $33.06 period with interpretation and report, same day (eg, diurnal curve or medical treatment of acute elevation of intraocular pressure) Ophthalmoscopy, extended, with retinal drawing (eg, for retinal 92225 $51.03 detachment, melanoma), with interpretation and report; initial

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Final Adoption Date Published in the Mass Register: February 14, 2025

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

.00: RATES FOR VISION CARE SERVICES AND OPHTHALMIC MATERIALS

Procedure Rate Description Code Ophthalmoscopy, extended, with retinal drawing (eg, for retinal 92226 $46.27 detachment, melanoma), with interpretation and report; subsequent Imaging of retina for detection or monitoring of disease; point- 92229 IC of-care autonomous analysis and report, unilateral or bilateral 92230 $78.79 Fluorescein angioscopy with interpretation and report 92260 $27.92 Ophthalmodynamometry 92275 $97.85 Electroretinography with interpretation and report External ocular photography with interpretation and report for 92285 $41.27 documentation of medical progress (eg, close-up photography, slit lamp photography, goniophotography, stereo-photography) Prescription of optical and physical characteristics of and fitting 92310 IC of contact lens, with medical supervision of adaptation; corneal lens, both eyes, except for aphakia 92326 $52.38 Replacement of contact lens 92340 $33.06 Fitting of spectacles, except for aphakia; monofocal Fitting of spectacles, except for aphakia; monofocal (replacement 92340 RB $10.17 and repair) (per lens) 92341 $40.80 Fitting of spectacles, except for aphakia; bifocal Fitting of spectacles, except for aphakia; bifocal (replacement 92341 RB $15.22 and repair) (per lens) Fitting of spectacles, except for aphakia; multifocal, other than 92342 $40.80 bifocal Fitting of spectacles, except for aphakia; multifocal, other than 92342 RB $15.22 bifocal (replacement and repair) (per lens) 92370 $12.07 Repair and refitting spectacles; except for aphakia 92499 IC Unlisted ophthalmological service or procedure Spontaneous nystagmus test, including gaze and fixation 92541 $47.25 nystagmus, with recording Positional nystagmus test, minimum of 4 positions, with 92542 $41.49 recording Optokinetic nystagmus test, bidirectional, foveal or peripheral 92544 $32.12 stimulation, with recording 99173 $24.28 Screening test of visual acuity, quantitative, bilateral

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Final Adoption Date Published in the Mass Register: February 14, 2025

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

.00: RATES FOR VISION CARE SERVICES AND OPHTHALMIC MATERIALS

Procedure Rate Description Code Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward 99202 $53.99 medical decision making. When using total time on the date of the encounter for code selection, 15 minutes must be met or exceeded. Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low level of medical 99203 $80.50 decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded. Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of 99204 $114.12 medical decision making. When using total time on the date of the encounter for code selection, 45 minutes must be met or exceeded. Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and high level of medical 99205 $144.59 decision making. When using total time on the date of the encounter for code selection, 60 minutes must be met or exceeded. Office or other outpatient visit for the evaluation and management of an established patient that may not require the 99211 $17.48 presence of a physician or other qualified health care professional Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and 99212 $32.19 straightforward medical decision making. When using total time on the date of the encounter for code selection, 10 minutes must be met or exceeded. Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level 99213 $44.49 of medical decision making. When using total time on the date of the encounter for code selection, 20 minutes must be met or exceeded.

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Final Adoption Date Published in the Mass Register: February 14, 2025

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

.00: RATES FOR VISION CARE SERVICES AND OPHTHALMIC MATERIALS

Procedure Rate Description Code Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate 99214 $69.65 level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded. Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level 99215 $101.38 of medical decision making. When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded. Office or other outpatient consultation for a new or established patient, which requires a medically appropriate history and/or 99242 $61.23 examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 20 minutes must be met or exceeded. Office or other outpatient consultation for a new or established patient, which requires a medically appropriate history and/or 99243 $79.04 examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded. Office or other outpatient consultation for a new or established patient, which requires a medically appropriate history and/or 99244 $110.19 examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded. Office or other outpatient consultation for a new or established patient, which requires a medically appropriate history and/or 99245 $149.03 examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 55 minutes must be met or exceeded. Inpatient or observation consultation for a new or established patient, which requires a medically appropriate history and/or 99252 $63.52 examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 35 minutes must be met or exceeded.

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Final Adoption Date Published in the Mass Register: February 14, 2025

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

.00: RATES FOR VISION CARE SERVICES AND OPHTHALMIC MATERIALS

Procedure Rate Description Code Inpatient or observation consultation for a new or established patient, which requires a medically appropriate history and/or 99253 $94.24 examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 45 minutes must be met or exceeded. Inpatient or observation consultation for a new or established patient, which requires a medically appropriate history and/or 99254 $135.78 examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 60 minutes must be met or exceeded. Initial nursing facility care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level of 99304 $51.28 medical decision making. When using total time on the date of the encounter for code selection, 25 minutes must be met or exceeded.

Initial nursing facility care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and moderate level of medical 99305 $68.53 decision making. When using total time on the date of the encounter for code selection, 35 minutes must be met or exceeded. Initial nursing facility care, per day, for the evaluation and management of a patient, which requires a medically appropriate 99306 $87.41 history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 50 minutes must be met or exceeded. Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires a medically appropriate 99307 $28.26 history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 10 minutes must be met or exceeded. Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires a medically appropriate 99308 $44.28 history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 20 minutes must be met or exceeded. 9

Final Adoption Date Published in the Mass Register: February 14, 2025

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

.00: RATES FOR VISION CARE SERVICES AND OPHTHALMIC MATERIALS

Procedure Rate Description Code Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and moderate level of medical 99309 $60.98 decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded. Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires a medically appropriate 99310 $60.98 history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 45 minutes must be met or exceeded. Home or residence visit for the evaluation and management of a new patient, which requires a medically appropriate history 99341 $47.20 and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 15 minutes must be met or exceeded. Home or residence visit for the evaluation and management of a new patient, which requires a medically appropriate history 99342 $69.24 and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded. Home or residence visit for the evaluation and management of a new patient, which requires a medically appropriate history 99344 IC and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 60 minutes must be met or exceeded. Home or residence visit for the evaluation and management of an established patient, which requires a medically appropriate 99347 $36.83 history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 20 minutes must be met or exceeded. Home or residence visit for the evaluation and management of an established patient, which requires a medically appropriate 99348 $57.91 history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded.

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Final Adoption Date Published in the Mass Register: February 14, 2025

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

.00: RATES FOR VISION CARE SERVICES AND OPHTHALMIC MATERIALS

Procedure Rate Description Code Home or residence visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical 99349 $88.90 decision making. When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded. T2002 $9.99 Nonemergency transportation; per diem

FRAMES Procedure Rate Description Code V2020 $60.30 Frames, purchases V2025 IC Deluxe frame

SINGLE VISION, GLASS OR PLASTIC If procedure code 92395 is reported, recode with specific lens type below. Procedure Rate Description Code V2100 $33.33 Sphere, single vision, plano to plus or minus 4.00, per lens Sphere, single vision, plus or minus 4.12 to plus or minus 7.00d, V2101 $35.14 per lens Sphere, single vision, plus or minus 7.12 to plus or minus 20.00d, V2102 $49.42 per lens Spherocylinder, single vision, plano to plus or minus 4.00d V2103 $28.97 sphere, 0.12 to 2.00d cylinder, per lens Spherocylinder, single vision, plano to plus or minus 4.00d V2104 $32.05 sphere, 2.12 to 4.00d cylinder, per lens Spherocylinder, single vision, plano to plus or minus 4.00d V2105 $34.91 sphere, 4.25 to 6.00d cylinder, per lens Spherocylinder, single vision, plano to plus or minus 4.00d V2106 $41.61 sphere, over 6.00d cylinder, per lens Spherocylinder, single vision, plus or minus 4.25 to plus or V2107 $36.82 minus 7.00 sphere, 0.12 to 2.00d cylinder, per lens

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Final Adoption Date Published in the Mass Register: February 14, 2025

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

.00: RATES FOR VISION CARE SERVICES AND OPHTHALMIC MATERIALS

Procedure Rate Description Code Spherocylinder, single vision, plus or minus 4.25d to plus or V2108 $38.13 minus 7.00d sphere, 2.12 to 4.00d cylinder, per lens Spherocylinder, single vision, plus or minus 4.25 to plus or V2109 $42.23 minus 7.00d sphere, 4.25 to 6.00d cylinder, per lens Spherocylinder, single vision, plus or minus 4.25 to 7.00d sphere, V2110 $42.45 over 6.00d cylinder, per lens Spherocylinder, single vision, plus or minus 7.25 to plus or V2111 $43.42 minus 12.00d sphere, 0.25 to 2.25d cylinder, per lens Spherocylinder, single vision, plus or minus 7.25 to plus or V2112 $47.40 minus 12.00d sphere, 2.25d to 4.00d cylinder, per lens Spherocylinder, single vision, plus or minus 7.25 to plus or V2113 $54.77 minus 12.00d sphere, 4.25 to 6.00d cylinder, per lens Spherocylinder, single vision, sphere over plus or minus 12.00d, V2114 $57.85 per lens V2115 $62.98 Lenticular (myodisc), per lens, single vision V2118 $83.22 Aniseikonic lens, single vision V2121 $71.95 Lenticular lens, per lens, single V2199 IC Not otherwise classified, single vision lens

BIFOCAL, GLASS OR PLASTIC Procedure Rate Description Code V2200 $47.07 Sphere, bifocal, plano to plus or minus 4.00d, per lens Sphere, bifocal, plus or minus 4.12 to plus or minus 7.00d, per V2201 $50.32 lens Sphere, bifocal, plus or minus 7.12 to plus or minus 20.00d, per V2202 $57.39 lens Spherocylinder, bifocal, plano to plus or minus 4.00d sphere, V2203 $46.75 0.12 to 2.00d cylinder, per lens Spherocylinder, bifocal, plano to plus or minus 4.00d sphere, V2204 $49.35 2.12 to 4.00d cylinder, per lens Spherocylinder, bifocal, plano to plus or minus 4.00d sphere, V2205 $52.48 4.25 to 6.00d cylinder, per lens

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Final Adoption Date Published in the Mass Register: February 14, 2025

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

.00: RATES FOR VISION CARE SERVICES AND OPHTHALMIC MATERIALS

Procedure Rate Description Code Spherocylinder, bifocal, plano to plus or minus 4.00d sphere, V2206 $54.74 over 6.00d cylinder, per lens Spherocylinder, bifocal, plus or minus 4.25 to plus or minus V2207 $53.06 7.00d sphere, 0.12 to 2.00d cylinder, per lens Spherocylinder, bifocal, plus or minus 4.25 to plus or minus V2208 $54.09 7.00d sphere, 2.12 to 4.00d cylinder, per lens Spherocylinder, bifocal, plus or minus 4.25 to plus or minus V2209 $61.26 7.00d sphere, 4.25 to 6.00d cylinder, per lens Spherocylinder, bifocal, plus or minus 4.25 to plus or minus V2210 $61.33 7.00d sphere, over 6.00d cylinder, per lens Spherocylinder, bifocal, plus or minus 7.25 to plus or minus V2211 $68.76 12.00d sphere, 0.25 to 2.25d cylinder, per lens Spherocylinder, bifocal, plus or minus 7.25 to plus or minus V2212 $74.81 12.00d sphere, 2.25 to 4.00d cylinder, per lens Spherocylinder, bifocal, plus or minus 7.25 to plus or minus V2213 $72.09 12.00d sphere, 4.25 to 6.00d cylinder, per lens Spherocylinder, bifocal, sphere over plus or minus 12.00d, per V2214 $71.27 lens V2215 $72.35 Lenticular (myodisc), per lens, bifocal V2218 $114.79 Aniseikonic, per lens, bifocal V2219 $37.90 Bifocal seg width over 28mm V2220 $30.73 Bifocal add over 3.25d V2221 $89.62 Lenticular lens, per lens, bifocal V2299 IC Specialty bifocal (by report)

TRIFOCAL, GLASS OR PLASTIC Procedure Rate Description Code V2300 $61.57 Sphere, trifocal, plano to plus or minus 4.00d, per lens Sphere, trifocal, plus or minus 4.12 to plus or minus 7.00d per V2301 $83.69 lens Sphere, trifocal, plus or minus 7.12 to plus or minus 20.00, per V2302 $93.07 lens

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Final Adoption Date Published in the Mass Register: February 14, 2025

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

.00: RATES FOR VISION CARE SERVICES AND OPHTHALMIC MATERIALS

Procedure Rate Description Code Spherocylinder, trifocal, plano to plus or minus 4.00d sphere, V2303 $62.06 0.12 to 2.00d cylinder, per lens Spherocylinder, trifocal, plano to plus or minus 4.00d sphere, V2304 $63.68 2.25 to 4.00d cylinder, per lens Spherocylinder, trifocal, plano to plus or minus 4.00d sphere, V2305 $79.35 4.25 to 6.00 cylinder, per lens Spherocylinder, trifocal, plano to plus or minus 4.00d sphere, V2306 $76.81 over 6.00d cylinder, per lens Spherocylinder, trifocal, plus or minus 4.25 to plus or minus V2307 $83.62 7.00d sphere, 0.12 to 2.00d cylinder, per lens Spherocylinder, trifocal, plus or minus 4.25 to plus or minus V2308 $86.13 7.00d sphere, 2.12 to 4.00d cylinder, per lens Spherocylinder, trifocal, plus or minus 4.25 to plus or minus V2309 $98.37 7.00d sphere, 4.25 to 6.00d cylinder, per lens Spherocylinder, trifocal, plus or minus 4.25 to plus or minus V2310 $83.27 7.00d sphere, over 6.00d cylinder, per lens Spherocylinder, trifocal, plus or minus 7.25 to plus or minus V2311 $95.63 12.00d sphere, 0.25 to 2.25d cylinder, per lens Spherocylinder, trifocal, plus or minus 7.25 to plus or minus V2312 $101.68 12.00d sphere, 2.25 to 4.00d cylinder, per lens Spherocylinder, trifocal, plus or minus 7.25 to plus or minus V2313 $110.82 12.00d sphere, 4.25 to 6.00d cylinder, per lens Spherocylinder, trifocal, sphere over plus or minus 12.00d, per V2314 $91.50 lens V2315 $135.42 Lenticular, (myodisc), per lens, trifocal V2318 $166.50 Aniseikonic lens, trifocal V2319 $45.29 Trifocal seg width over 28 mm V2320 $44.58 Trifocal add over 3.25d V2321 $132.23 Lenticular lens, per lens, trifocal V2399 IC Specialty trifocal (by report)

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Final Adoption Date Published in the Mass Register: February 14, 2025

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

.00: RATES FOR VISION CARE SERVICES AND OPHTHALMIC MATERIALS

VARIABLE ASPHERICITY Procedure Rate Description Code Variable asphericity lens, single vision, full field, glass or plastic, V2410 $76.31 per lens Variable asphericity lens, bifocal, full field, glass or plastic, per V2430 $93.80 lens V2499 IC Variable sphericity lens, other type

CONTACT LENSES If procedure code 92396 is reported, recode with specific lens type listed below (per lens). Procedure Rate Description Code V2500 $72.55 Contact lens, PMMA, spherical, per lens V2501 $140.53 Contact lens, PMMA, toric or prism ballast, per lens V2502 $170.42 Contact lens PMMA, bifocal, per lens V2503 $159.44 Contact lens, PMMA, color vision deficiency, per lens V2510 $107.81 Contact lens, gas permeable, spherical, per lens V2511 $180.96 Contact lens, gas permeable, toric, prism ballast, per lens V2512 $189.61 Contact lens, gas permeable, bifocal, per lens V2513 $153.63 Contact lens, gas permeable, extended wear, per lens V2520 $50.77 Contact lens, hydrophilic, spherical, per lens V2521 $77.98 Contact lens, hydrophilic, toric, or prism ballast, per lens V2522 $95.74 Contact lens, hydrophilic, bifocal, per lens V2523 $80.46 Contact lens, hydrophilic, extended wear, per lens Contact lens, scleral, gas impermeable, per lens (for contact lens V2530 IC modification, see 92325) Contact lens, scleral, gas permeable, per lens (for contact lens V2531 IC modification, see 92325) V2599 IC Contact lens, other type

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Final Adoption Date Published in the Mass Register: February 14, 2025

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

.00: RATES FOR VISION CARE SERVICES AND OPHTHALMIC MATERIALS

LOW-VISION AIDS If procedure code 92392 is reported, recode with specific systems listed below. Procedure Rate Description Code V2600 IC Handheld low vision aids and other nonspectacle mounted aids V2610 IC Single lens spectacle mounted low vision aids Telescopic and other compound lens system, including distance V2615 IC vision telescopic, near vision telescopes and compound microscopic lens system

PROSTHETIC EYE Procedure Rate Description Code V2623 IC Prosthetic eye, plastic, custom V2624 IC Polishing/resurfacing of ocular prosthesis V2625 IC Enlargement of ocular prosthesis V2626 IC Reduction of ocular prosthesis V2627 IC Scleral cover shell V2628 IC Fabrication and fitting of ocular conformer V2629 IC Prosthetic eye, other type

INTRAOCULAR LENSES Procedure Rate Description Code V2630 IC Anterior chamber intraocular lens V2631 IC Iris supported intraocular lens V2632 IC Posterior chamber intraocular lens

MISCELLANEOUS Procedure Rate Description Code V2700 $39.08 Balance lens, per lens V2710 $54.56 Slab off prism, glass or plastic, per lens 16

Final Adoption Date Published in the Mass Register: February 14, 2025

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

.00: RATES FOR VISION CARE SERVICES AND OPHTHALMIC MATERIALS

Procedure Rate Description Code V2715 $9.88 Prism, per lens V2718 $31.43 Press-on lens, Fresnel prism, per lens V2730 $18.40 Special base curve, glass or plastic, per lens V2744 $13.96 Tint, photochromatic, per lens Addition to lens; tint, any color, solid, gradient or equal, excludes V2745 $8.67 photochromatic, any lens material, per lens V2750 $16.24 Antireflective coating, per lens V2755 $18.84 U-V lens, per lens V2760 $14.35 Scratch resistant coating, per lens V2770 $22.15 Occluder lens, per lens V2780 $11.68 Oversize lens, per lens V2781 IC Progressive lens, per lens V2785 IC Processing, preserving and transporting corneal tissue V2788 IC Presbyopia correcting function of intraocular lens V2799 IC Vision item or service, miscellaneous

315.05: Severability

The provisions of .00 are severable. If any provision of .00 or application of any provision to an applicable individual, entity, or circumstance is held invalid or unconstitutional, that holding will not be construed to affect the validity or constitutionality of any remaining provisions of .00 or application of those provisions to applicable individuals, entities, or circumstances.

REGULATORY AUTHORITY

.00: M.G.L. c. 118E

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