( ) Dr. Michael Shea
( ) Eye Optique
Health / Vision Insurance Claim Form:
YOUR EYECARE $I VICES WERE PROVIDED BY:
Date:
Patient's Name:
Last
First
Address:
Street
DOB:
ID#:
Your Phone#:
-
Zip
City/State
Insurance Company
SS#:
Email Address:
PRZYCEDURE TCODES.
SOURCE CURRENT PROCEDURAL TERMINOLOGY - 4TH EDITION
EXAMINATION SERVICES
New
Intermediate Ophthalmic
Comprehensive Ophthalmic
Office Visit 10
Office Visit 20
Office Visit 30
Office Visit 45
Office Visit 60
Refraction
92002
92004
99201
99202
99203
99204
99205
Established
Fee
92012
92014
99211
99212
99213
99214
99215
92015
SPECIAL PROCEDURES .
Biomicroscopic photography
Chalazion, single
Chalazion, multiple
Color vision extended
Dark Adaptometry extended
Electro-Oculography EOG
ElectroRetinography ERG
Epilation for trichiasis
Foreign body corneal
Foreign body conjunctival
Foreign body eyelid
Gonioscopy
Lacrimal Irrigation
Ophthalmoscopy 810/VOLK
Punctal dilation
Punctal Implant (per duct)
Refraction
Retinal Photography
Sensorimotor Evaluation
Trichiasis - electrolysis
Tonometry, serial
Ultrasound - A (with IOL talc.)
Contact B Scan
Visual Fields - limited
Visual Fields - quantitative
Visual Fields - static threshold
Visually Evoked Potential
Unlisted special procedures
Other codes
Other codes
92285
67800
67801
92283
92284
93370
93375
67820
65222
65210
67938
92020
68840
92225
68800
68761
92015
92250
92060
67825
92100
76519
76512
92081
92082
92083
92280
92499
LOW VISION AND VISUAL THERAPY SERVICES
Amblyopia Therapy - BV
Binocular Vision Therapy non-strabismus - BV
Design/prescribe Spectacle/single element aid • LV
Design/prescribe Compound element aid - LV
Developmental testing - higher functions - DV
Developmental therapy - DV
Neuromuscular Re-education
Ocular Motility Studies
Oculomotor Therapy
Orthoptics - Visual Therapy - per session - BV
Strabismus therapy - rehabilitation - BV
Unlisted neurological/neuromuscular diagnostic
98681
98683
92354
92355
95881
98684
97112
98316
98685
92065
98682
95999
CONTACT LENS PROFESSIONAL SERVICES
Aphakia, diagnostic fitting, one eye
Aphakia, diagnostic fitting, two eyes
Contact Lens Modification - professional services
Contact lens fitting non-aphakic prof. services
Contact lens Replacement - professional services
Contact lens Therapeutic - includes lens
92311
92312
92325
92310
92326
92070
CONTACT LENS MATERIALS SERVICES
Aphakia, supply new contact lens, per lens
Non-aphakia, supply new contact lens, per lens
Eye Optique
10800 Alpharetta Highway
Suite 220
Roswell, Georgia 30076
770-642-7720
( ) Dr. Michael Shea NPl#: 1124146469
0 Edward Kleinman LDO NPl#:
158084961
( ) Eye Optique NPlit: 1912108119
) Eye Opticue Tax ID#: 58-1672353
DIAGNOSIS AND/OR CONCURRENT CONDITIONS:
ICD-9-CM
Abnormal Pupil Reflexes
Accomm. Dyst
Amaurosls Fugax
Amblyopia, Anisometropic
Amblyopia, Strabismic
Aphakia
Pseudophakia
Arthritis multiple sites
Binocular Dysf
Blepharitis
Blepharochalasis
Blepharospasm
Burn, eye(s) (unspec.)
Cataract, late onset PSC
Cataract, late onset Cortical
Cataract, late onset NS
Cataract, Incipient
Cataract, mature
Cataract: "After"
Chalazion
Chorioretinal Scars
Chorioretlnitis
Color Vision Defect
Conjunctivitis, Mucopurulent
Conjunctivitis, Follicular
Conjunctivitis, Allergic
Conjunctivitis, Viral
Conjunctival Hemmorrhage
Convergence Excess
Convergence Insuff
Corneal, Abrasion
Corneal, Erosion (RCE)
Corneal, Neovascular
Corneal, Endo Pigment
Corneal, Opacity (idiopathic)
Corneal Ulcer (unspecified)
Development, disorder
Development, delay in
Diabetes, eye manifestations
Diplopia
Drusen, Disc
Drusen, Retinal
Dry Eyes
Ecchymosis
Ectropion
Entropion
Epiphora
Episcieritis, Nodular
Episcieritis, Spec
Esophorla
Exophoria
Exophthalmos
Eye, contusion
Eye, pain in or around
Eye, redness or discharge
Eyelid, inflam. (unspec)
Eyelid, neoplasm (benign)
Foreign body, corneal
Foreign body, eyelid
GLC, Open Angle - Suspect
GLC, Suspect - Ocular HTN
GLC, Open Angle - Chronic
GLC, Open Angle - Low Ten
GLC, Pigmentary
379.40
36750
362.34
368.03
368.01
379.31
V43.1
716.99
368.30
373.00
374.34
333.81
940.90
366.14
366,15
366.16
366.12
366.17
366.53
373.20
383.30
363.20
368.50
372.03
372.12
372.14
077.90
372.72
378.84
378.83
918.10
371.42
370.61
371.13
371.21
370.00
315.50
315.80
250.50
368.20
377.21
36257
375.15
921.00
374.10
374.00
375.20
379.02
379.09
378.41
378.42
376.30
921.90
379.91
379.93
373.90
216.10
930.00
374.86
365.01
365.04
365.11
365.12
365.13
GLC, Anatom Narrow Angles
GLC, Narrow Intermittent
GLC, Narrow-Acute
Headache
Histoplasmosis - POHS
H. Simplex, Ophthalmic
H. Zoster, Ophthalmic
Hordeolum
Hyperemia, Ocular
Hyperphoria
Hyphema
Iridocyclitia
Iris, Synechlae (unspec)
Keratitis, SPK
KeratoconjunctIvitis
Keratoconus
Macular Degeneration DRY
Macular Degeneration WET
Meibomianitis
Metamorphopsie
Migraine, unspecified
Nevus, Choroidal
Night Blindness (unspec)
Normal
Nystagmus, irreg. EM
Ocular motor dsyf
Optic Atrophy
Optic Neuropathy, 'Bohemia
Palsy, NIII
Palsy, NIV
Palsy, NVI
Papilledema
Photophobia
Photopsia
Pigmentary dispersion
Pinguecula
Pseudo-Tumor, Orbital
Pterygium
Ptosis
Pursuit EM deficiency
Refractive change, transient
Retinal detach
Retinopathy (8DR)
Retinopathy, Hypertensive
Retinopathy, CRAO
Retinopathy, CRVO
Retinopathy, BRAO
Rebnopathy, 8RVO
Retinopathy, Vein Engorgement
Retinopathy, Hemorrhage
Saccadic EM deficiency
Scleritis
Strabismus, accommodative
Strabismus, convergent
Strabismus, divergent
Strabismus, vertical
Toxoplasmosis - ocular
Thyroid, disorder
Trichiasis
Vision Loss Transient (TVO)
Visual Field Defect
Vitreous detachment - PVD
Vitreous floaters
Xanthelasma
365.02
365.21
385•22
784.00
115.02
054.40
053.20
373.10
372.71
378,43
921.30
364.00
364.70
370.21
370.33
371.60
362.51
362.52
373.12
368.14
34690
224.60
368.60
V65.50
379.50
378.90
377.11
377.41
378.51
378.53
378.54
377.01
368.13
388.15
364.53
37251
379.11
372.40
374.30
37958
367.81
361.00
362.01
362.11
362.32
362.35
36231
362.36
362.37
362.81
379.57
379.02
378.35
378.00
378.10
378.31
130.20
242.00
374.05
368.12
368.40
379.21
379.24
374,51
OPHTHALMIC MATERIALS PROFESSIONAL SERVICES
Aphakia, treatment with spectacles SV
Aphakia, treatment with spectacles multifocal
Aphakia, prosthesis services
Treatment with spectacles SV, except aphakia
Treatment with spectacles BF, except aphakia
Treatment with spectacles multifocal TF etc
Repair and adjustment, except aphakia
92352
92353
92358
92340
92341
92342
92370
SPECIAL SERVICES AND REPORTS
After hours services
Sunday and Holiday Services
Services provided out-of-office
Medical/Optometric Testimony
Special Reports
Unlisted special services
99050
99054
99056
99075
99080
92499
ASSIGNMENT AND RELEASE:
I HEREBY AUTHORIZE THE PHYSICIAN TO RELEASE ANY INFORMATION
REQUIRED TO PROCESS THIS CLAIM. I ALSO AUTHORIZE MY
INSURANCE BENEFITS BE PAID DIRECTLY TO THE PHYSICIAN, AND I
UNDERSTAND I AM FINANCIALLY RESPONSIBLE FOR NON-COVERED
SERVICES.
Date
SIGNED
Note: Refractive diagnosis
and eyeglasses are usually
covered by eyeglass plans-not major medical.
REFRACTIVE DIAGNOSIS
367.1
Myopia
367.0
Hyperopia
367.4
Presbyopia
367.20
Astigmatism
Additional Diagnosis
MATERIALS
Frames
SV Lenses
BF Lenses
TF Lenses
Aphakic BF
Photochr
UV400
Tint
Prism
Stab-Off
Oversized
EW CL Aph
CI. COS
Fees
V2020
V210
RT/LT
V220_ KILT
RT/LT
V230_
V2430 RT/LT
V2744 RT/LT
V2755
RT/LT
V2740 RT/LT
V2715 RT/LT
RT/LT
V2710
V2780 RT/LT
V2523 RT/LT
V25_ RT/LT
Total Fees:
Accept Assignment:
Adjustments/ Insurance Discounts: S
( ) YES ( ) NO
Amount Paid Today:
( ) CoPsyments
Balance Due from Insurance Co: S
Date:
NEXT APPOINTMENT
Prnviriae / A