CPT 92015: billing refraction (and why Medicare doesn't pay it)

CPT 92015 reports a refraction: determining the refractive state of the eye — the measurement a glasses or contact lens prescription comes from.

It reports as its own line on the claim, separate from the exam code that covers the visit itself.

The split matters because payers do not treat the two lines the same way.

Medicare is the sharpest edge.

CMS groups refractions with eyeglasses, contact lenses and eye examinations for prescribing, fitting or changing glasses in one exclusion, and that grouping decides how your front desk quotes a routine visit to a Medicare patient.

This page walks the rule and the workflow around it: why the exclusion exists, what notice the patient needs, where the fee comes from, and what other payers do with the code.

The exclusion sits in federal regulation.

42 CFR 411.15(c) keeps out eye examinations for prescribing, fitting or changing glasses or contacts for refractive error, and refractive procedures "even when performed in connection with otherwise covered diagnosis or treatment."

CMS's Benefit Policy Manual (Chapter 16, section 90) states it operationally: eye refractions are excluded "by whatever practitioner and for whatever purpose performed," alongside eyeglasses, contact lenses and the exams that prescribe them.

The exclusion does not care who performs the refraction or why.

CMS applies it whether an ophthalmologist or an optometrist does the work, without regard to the reason — so a medical diagnosis on the visit does not turn 92015 into a covered service.

On the 2026 Medicare Physician Fee Schedule the code carries status N, which CMS defines as non-covered services.

There is no fee-schedule payment behind the line at all.

That is the split that matters at the front desk: the same visit can carry a covered exam and an uncovered refraction.

The routine-eye exclusion does not reach physicians' services furnished in conjunction with an eye disease such as glaucoma or cataracts — which is why a medically necessary exam can bill to Medicare while its refraction line still cannot.

The exam-side rules live in our guide to optometry billing and coding.

Status codes and coverage rules come from CMS's fee files and manuals and can change.

Confirm the current status of any code with CMS and your Medicare Administrative Contractor before you build a workflow on it.

The mandatory Advance Beneficiary Notice (form CMS-R-131) exists for a different situation: services Medicare is expected to deny as not reasonable and necessary.

CMS's ABN guidance, updated May 2025, draws that line.

Refraction is not that case.

CMS does not require an ABN before providing a service Medicare never covers, so a statutorily excluded refraction needs no signed notice at all.

What a practice may do instead is give a voluntary notice as a courtesy.

It alerts the patient to their financial liability, does not change who owes the money, and does not need a signature.

Do not paper the whole schedule while you are at it.

CMS prohibits issuing ABNs routinely — blanket ABNs — outside listed exceptions: experimental services, services with statutory or NCD/LCD frequency limits, and services always denied as medically unnecessary.

The distinction has teeth on the mandatory track.

When a required ABN is missing, or your MAC finds the one on file invalid, CMS may hold the practice financially liable for the service — and the practice cannot then collect it from the patient.

None of that exposure sits under a refraction line, which is why the fee conversation below is a financial-policy task, not a notice-form task.

On the claim, the matching modifiers come from the same guidance: GY reports an item or service that is statutorily excluded or not a Medicare benefit — refraction is CMS's own example — and GX reports that a voluntary notice was issued.

GA and GZ belong to the reasonable-and-necessary track.

Start from what the fee is not: there is no Medicare allowance.

Status N means no fee-schedule payment exists for 92015, so there is no Medicare amount to write the charge against.

That makes the refraction fee a price your practice sets, like any other self-pay service.

Decide what the service costs the practice to deliver, set a listed charge, and hold it consistent from patient to patient.

Tell the patient before the visit.

A refraction charge that first appears on the receipt reads as a surprise; one quoted at scheduling and repeated at check-in gives the patient the same information twice.

If your practice uses the voluntary notice CMS allows, it doubles as that conversation in writing.

Folding the refraction fee into a posted financial policy does the same job for every patient, whether or not a notice form is involved.

Keep the charge visible as its own line on the estimate and the receipt.

Medicare patients can then see why the exam went to Medicare and the refraction did not — the split the exclusion creates, on paper where they can read it.

Where a payer contract or a state rule touches patient billing, confirm it with the payer or your advisor before you publish the policy.

Then make sure someone owns the line day to day: the script lives with your front desk and the modifier with your billing staff.

If the practice needs either, hiring for your optometry practice starts with one posting on a board that lists only eye care work.

Medicare's rule is the only one this page can state with a citation, because other payers set their own 92015 policies and our research did not test them.

Treat "is refraction covered" as a per-payer question with a per-payer answer.

On Original Medicare claims the answer never changes: the refraction is the patient's to pay, reported with GY.

Medicare Advantage plans were not covered by our research, so check their refraction rules like any other plan's.

For everyone else, the plan's contract decides — whether refraction is a plan benefit, a patient charge, or bundled into a routine exam benefit.

The code set hints at the split.

The routine-exam codes S0620 and S0621 — a routine ophthalmological exam including refraction, in new- and established-patient versions — are status I on the Medicare fee schedule: not valid for Medicare, though some commercial and vision plans use them.

Which plans accept those codes was not confirmed by our research, so verify code acceptance with each payer rather than copying a list.

Medicaid was outside our research as well; ask your state Medicaid agency how it treats refraction rather than assuming Medicare's rule carries over.

Ask the plans you panel with to state their refraction and same-day medical-plus-routine rules in writing, and keep the answer with the contract.

The plan's own documents, not a colleague's memory, are the authority on its terms.

This page is employer information, not medical, licensing, legal, billing or coding advice; confirm refraction coverage, notice and modifier rules with CMS, your MAC and each payer before you bill.