General Rules

Rule

Rule Description

001

The service of a registered Optometrist shall be available only on written referral by the treating doctor / Opthalmologist.

The medical treating doctor / Opthalmologist must clearly indicate the reason for the referral, relationship to the original injury.

The referral may be on the service provider's (Optometrist) letterhead, provided it is signed by the referring doctor.

002

Medical invoices should be accompanied by vision reports

003

Optometry services should be rendered to Out-patients only.

004

Spectacles will only be renewable after a period of 2 years with motivation. Pre-authorization is required for spectacles.

Tariff Codes

Code

Code Description

Rand

11001

Optometric Examination

Note: Relevant for replacement of spectacles

690.95

11046

Ocular Pathology Examination

Note: When occupational injury/disease related

777.17

11061

Low Vision Examination

Note: When occupational injury/disease has caused deterioration of vision to sub-standard levels, or following occupational injury/disease incident of low-vision patient.

958.22

11141

Refractive Status evaluation

Note: Appropriate post occupational injury/disease incident to monitor recovery of the eye.

266.16

11183

Keratometry

Note: Appropriate for monitoring of corneal recovery after occupational injury/disease to the eye

133.14

11202

Tonometry without anaesthetic

Note: After ocular occupational injury/disease cases only

159.74

11212

Tonometry with anaesthetic

Note: After ocular occupational injury/disease cases only

212.95

11246

Colour Vision Evaluation

Rule: Can be billed with 11001 or 11046

244.85

11265

Contrast Sensitivity Evaluation

Rule: Can be billed with 11001 or 11046

150.63

11356

Gonioscopy

Rule: Can be billed with 11001 or 11046

332.79

11366

Dilated fundus examination with Fundus lens

Rule: Can be billed in addition to 11001 or 11046 when necessary

330.08

11402

Visual field - screening

Note: Relevant in cases of head and/or ocular injury

170.34

11423

Visual field - Non threshold testing

Rule: Can be billed with 11001 or 11046

212.95

11443

Visual field - Threshold testing

Rule: Can be billed with 11001 or 11046

372.70

11604

Photography of Anterior Segment

Rule: Can be billed with 11001 or 11046

106.41

11624

Photography of Fundus

Rule: Can be billed with 11001 or 11046

170.34

11702

Pachymetry

Rule: Can be billed with 11001 or 11046

149.03

11802

Optical Coherence Tomography (OCT) Health screening

Rule: Can be billed with 11001 or 11046

308.77

11803

Optical Coherence Tomography (OCT) Anterior

Rule: Can be billed with 11001 or 11046

223.54

11804

Optical Coherence Tomography (OCT) Posterior

Rule: Can be billed with 11001 or 11046

266.16

11838

Glaucoma investigation code

When occupational injury/disease related.

276.87

11906

Lacrimal Drainage System Patency

Rule: Can be billed in addition to 11001 or 11046 in cases such as chemical or vapour exposure

393.88

15000

Removal of non embedded foreign body

Rule: Can be billed with 11001 or 11046 or 11061 or 15025 or 15030

255.57

15002

Removal of embedded; non-penetrating foreign body

Rule: Can be billed with 11001 or 11046 or 11061 or 15025 or 15030

373.19

15004

Removal of corneal foreign body

Rule: Can be billed with 11001 or 11046 or 11061 or 15025 or 15030

484.53

15025

Management of ocular pathology

Rule: Cannot be billed with 15030 or 11001 or 11046 or 11061

936.91

15030

Management of ocular pathology - follow up

Rule: Cannot be billed with 15025 or 11001 or 11046 or 11061

670.75

Lens

Code

Code Description

Rand

11501

Dispensing fee - single vision basic

Rule: Only with replacement of spectacle lenses code 81BS001

95.82

11521

Dispensing fee - Bifocals

Rule: Only with replacement of spectacle lenses code 84BS001

127.72

11541

Dispensing fee -Varifocal distance to near

Rule: Only with replacement of spectacle lenses code 86BS001

159.74

11503

Dispensing fee - Single Vision Surfaced

Rule: Only with replacement of spectacle lenses code 82BS001

127.72

11531

Dispensing Fee - Accommodative Support

Rule: Only with replacement of spectacle lenses code 83BS001

127.72

11540

Dispensing fee - Intermediate to near

Rule: Only with replacement of spectacle lenses code 85BS001

127.72

Note

For Single vision, Bifocal, Varifocal the below applies

LENS CODES: Replacement lenses after ocular injury if lenses were broken or if treatment changed due to occupational injury/disease incident.

Rule: A claim is limited to a maximum of 2 replacements. Occasionally there may be a combination of 2 different codes, but never a code starting with 8 together with a code starting with 7

81BS001

Single Vision (standard) CR39

266.77

82BS001

Single Vision (surfaced) CR39

600.92

83BS001

Accommodative support lens

600.92

84BS001

Bifocals CR39

671.00

85BS001

Varifocal Intermediate to near

1164.77

86BS001

Varifocal Distance to near

1164.77

71BS001

Single Vision (standard) Glass

266.77

72BS001

Single Vision (surfaced) Glass

600.92

74BS001

Bifocal Glass

671.00

76BS001

Varifocal Distance to Near Glass

1164.77

40501

Spectacle frame

Note: Frame and lens will only be issued if the eye condition is due to occupational injury/disease.

Rule: Refer to rule 004

1097.41

Note

For Unbranded High Refractive Index (HRI) the below applies:

LENS ENHANCEMENTS CODES:Where lenses are replaced as result of occupational injury/disease, and treatment is greater than

+4.00D (sphere) or -6.00D (sphere + cyl,or cyl is greater than -2.00)

Note: First 2 digits must align with first 2 digits of lens codes

81UB003

Unbranded HRI single vision stock

3032.68

83UB002

Unbranded HRI Accommodative Support

2244.43

86UB006

Unbranded HRI Varifocal Distance/Near

2657.03

Note

Where occupational injury/disease resulted in Low Vision status (normal visual function cannot be achieved with spectacles) one or more low vision devices are appropriate.

61013

LVA - Single Element

2960.69

61114

LVA - Multiple Elements Fixed Focus

3079.11

61215

LVA - Multiple Element Variable focus

17764.12

61318

LVA - Electronic

14211.29

61320

Software aided vision program

1539.56

Ocular Prosthetics

Note

Claims for Ocular Prostheses are for the fitting of a prosthesis after removal of the eye due to injury or pathology, and replacement of the prosthesis at the end of its life, and for the maintenance of the prosthesis in the interim.

Correctly manufactured and maintained prostheses should last approximately 60 months. They should be annually 'serviced' to maintain the surface of the prosthesis and thereby prevent deterioration and / or physiological issues from reducing the lifespan of the prostheses and / or resulting in the need for additional medical or surgical  intervention.

56000

Complete Eye

Note: Where occupational injury/disease has resulted in the enucleation (removal) of the eye. The code covers all aspects of the fitting of a complete prosthesis, including 6 months of after care.

Note: Repeats are allowed without intervention after 60 months.

28162.31

56001

Polishing

482.47

56010

Complete Haptic Shell

Note: Where occupational injury/disease has damaged and blinded the eye, but not necessitated enucleation. The code covers all aspects of the fitting of a complete prosthesis, including 6 months of after care.

Note: Repeats are allowed without intervention after 60 months.

4527.73

59001

Annual Maintenance

Note: Not billable within 6 months of the fitting of code 56000 or 56010 prosthesis.

Code can be billed together with 53015.

3009.77

53015

Prosthetic Consultation

Rule: Billed together with 59001, or where annual visit codes 56000 or 56010 Can be billed but does not necessitate maintenance 59001

945.04

70081

Optometric examination and visual field screening consultation

685.76

70021

Optometric re-examination within six months of 70081 followup

391.93

70503

Walking Stick/Cane for the blind

427.38