Eye surgery (Ophthalmology) services in Medicare 011-20062640

Ophthalmology is the branch of medicine concerned with the study and treatment of disorders and diseases of the eye. Ophthalmologists are specialists or consultant physicians for Medicare purposes.

The Medicare Benefits Schedule (MBS) lists Medicare items for ophthalmology services. This document provides general information about assessing claims for ophthalmology services in Medicare.

See Optometrical services assessing rules in Medicare for information about glasses, lenses and other allied health services for eyes and vision.

MBS items for eye services are in:

• Category 2, Group D1, Miscellaneous diagnostic procedures and investigations, items 11200 – 11244
• Category 3, Group T8, Subgroup 9, Ophthalmology, items 42503 - 43023

Service Officers need to check all relevant explanatory notes including QITI before providing advice. If additional clarification of the item description or explanatory notes are required, refer to a Local Peer Support (LPS) or Team Leader.

The Resources page has information about frequently claimed MBS items.

The text or notation for eye surgery is very important as it allows a Service Officer to record which eye the surgery was performed on. Once the operator adds LSE or RSE to the claiming screen, this information is stored on the patient’s history and will make it easy for operators who are processing future claims.

The Resources page has more information about appropriate text notations and how to key which eye was treated in different processing systems.

Eye surgery items in the MBS include whether they are for 1 or both eyes in the item description.

• Unilateral means occurring on, performed on, or affecting 1 side (1 eye)
• Bilateral refers to both sides of the body, or affecting the right and left sides (both eyes)

Note: health professionals must submit text with their claims for unilateral items indicating which eye was treated (for example, left or right).

The Resources page has information about frequently claimed items and whether the items are for 1 or both eyes.

The Health professionals must be registered with Medicare as an Ophthalmology specialist to claim Medicare benefits.

More information about speciality codes can be located in Provider specialty codes and the Provider Directory System (PDS).

The Resources page has a link to the Australian Health Practitioner Regulation Agency (Ahpra) website about recognition for an ophthalmologist.

A standard ophthalmic exam is a comprehensive series of tests done by an ophthalmologist. These tests check both the vision and health of the patient’s eyes with:

• Angiography
• Electroretinography
• Ultrasonography
• Pachymetry
• Optical Coherence Tomography
• Computed Tomography (CT) and Magnetic Resonance Imaging (MRI)

The Resources page has a link to the specific items in Category 2, Group D1, and Subgroup 2 – Ophthalmology on MBS Online.

The Resources page also has a table of frequently claimed items and the text that must be submitted with claims.

Eye surgery, also known as ocular surgery, is surgery performed on the eye, typically by an ophthalmologist.

The list below shows the more common eye surgeries:

• Laser eye surgery
• Cataract surgery
• Glaucoma surgery
• Refractive surgery
• Corneal surgery
• Vitreoretinal surgery
• Eye muscle surgery

Medical terminology for ophthalmology is complicated. The Resources page has a list of medical terminology used by eye surgeons to assist when assessing claims.

The Resources page has a link to the specific items in Category 3, Group T8, and Subgroup 9 – Ophthalmology on MBS Online.