Georgia Medicare Optometry Services Coverage

Georgia Medicare Optometry Services

Medicare pays for a Georgia beneficiary's cataract surgery, glaucoma treatment, and diabetic eye exams, but not the routine eye exam and glasses most people picture at the eye doctor. Knowing where that line falls is what separates a covered visit from a surprise bill, and it is the heart of how Georgia Medicare optometry services are paid for. Age-related cataracts, glaucoma, macular degeneration, and diabetic retinopathy affect a large share of the Medicare population, yet Medicare's coverage of routine eye care is one of the most narrowly bounded benefits in Part B, structured around the statutory exclusion of routine eye examinations and eyeglasses at Section 1862(a)(7) with specific exceptions for cataract surgery, glaucoma screening, and medical eye disease.

The framework rests on five pillars of federal law. Section 1861(r)(4) of the Social Security Act recognizes doctors of optometry as Medicare physicians. The recognition was added by Section 9337 of the Omnibus Budget Reconciliation Act of 1986 (Public Law 99-509). Before OBRA 1986, optometrists were not Medicare-recognized physicians; ophthalmologists (M.D.s and D.O.s with ophthalmology training) were the only Medicare-recognized eye-care providers. The 1986 expansion reflected congressional recognition that optometrists could deliver many ocular services at lower cost than ophthalmologists, particularly for medical eye conditions within optometric scope.

Section 1862(a)(7) of the Social Security Act excludes from coverage "routine physical checkups, eyeglasses... or eye examinations for the purpose of prescribing, fitting, or changing eyeglasses, procedures performed (during the course of any eye examination) to determine the refractive state of the eyes..." The implementing regulation at 42 CFR 411.15(b) operationalizes the statutory exclusion. The distinction between routine eye care (excluded) and medical eye care (covered) governs the entire framework.

Two important exceptions sit alongside the exclusion. Section 1861(s)(8) covers the intraocular lens implanted during cataract surgery as a prosthetic device, plus one pair of conventional eyeglasses or contact lenses furnished after each cataract surgery. This benefit has been in the statute since the original 1965 enactment as part of the prosthetic device benefit. Section 1861(s)(10), added by Section 102 of the Benefits Improvement and Protection Act of 2000 (Public Law 106-554), covers glaucoma screening for high-risk beneficiaries. The implementing regulation is at 42 CFR 410.23. Annual screening is available for diabetics, family-history patients, African Americans aged 50 and older, and Hispanic Americans aged 65 and older.

A third de facto exception is the standard coverage of medically necessary eye care for disease. Treatment of glaucoma (diagnosis, medical management, laser, surgery), macular degeneration (including anti-VEGF injections), diabetic retinopathy (laser photocoagulation, vitrectomy), retinal detachment, corneal disease, dry eye syndrome, and other ocular diseases is covered under standard Part B physician services. Diabetic eye examinations are covered annually as part of medically necessary diabetic care. Annual eye examinations for non-disease vision check, however, remain excluded.

In Georgia, the rules play out through licensed optometrists overseen by the Georgia State Board of Optometry under O.C.G.A. §43-30. Georgia is one of the more progressive states for optometric scope of practice. Successive amendments including SB 153 have expanded Georgia O.D. scope to include therapeutic agents (oral and topical), management of ocular disease including glaucoma, certain laser procedures with credentialing, and prescription of controlled substances for specific eye conditions. Palmetto GBA serves as the Medicare Administrative Contractor for Jurisdiction J, covering Georgia, Alabama, and Tennessee, and administers Medicare optometry and ophthalmology claims under federal NCDs and regional LCDs.

This guide walks through each layer of the framework: the statutory recognition of optometrists, the routine eye examination exclusion, the post-cataract IOL and eyewear benefit, the glaucoma screening benefit, the diabetic retinopathy framework, cataract surgery coverage, wet AMD treatment with anti-VEGF, glaucoma diagnosis and management, the HCPCS coding architecture for optometric services, the Georgia optometric landscape, and 14 common mistakes. Four Georgia case studies illustrate common patient situations: a diabetic eye examination, cataract surgery with post-cataract eyewear, glaucoma screening for an African American beneficiary, and a routine eye examination with ABN self-pay. A frequently-asked-questions accordion and a Georgia contact directory close the guide.

The clinical case for understanding Medicare eye care rules

Understanding Georgia Medicare optometry services begins with the clinical stakes for older adults. Before the legal framework, those stakes deserve attention: older adults face a remarkable burden of eye disease. Cataracts are among the most common age-related conditions, and cataract surgery is among the most commonly performed Medicare surgical procedures. Glaucoma is a leading cause of irreversible blindness, with disproportionate burden on Black Americans and Hispanic Americans. Age-related macular degeneration, with the wet form treatable with anti-VEGF injections, can cause rapid vision loss without treatment.

Diabetic retinopathy is common among diabetic adults aged 40 and older. Proliferative diabetic retinopathy and diabetic macular edema can cause blindness without timely treatment with laser photocoagulation, anti-VEGF injections, or vitrectomy. Vision impairment is associated with falls (a leading cause of injury death in older adults), depression, cognitive decline, and loss of independence.

Effective eye care for older adults requires regular screening (for glaucoma, diabetic retinopathy, AMD), timely diagnosis and treatment of disease, surgical management of cataracts when vision becomes functionally impaired, and ongoing management of chronic eye conditions. Medicare's coverage rules are designed to cover the medical and surgical aspects of this care while excluding routine refractive eye examinations and eyeglasses, which are viewed as services beneficiaries can obtain through community-based optometry and optical providers on a fee-for-service basis (or through Medicare Advantage supplemental vision benefits).

Understanding the rules helps Georgia beneficiaries and their families ensure that medically necessary care is properly billed and that they understand what they can expect to pay out of pocket for the routine vision care they need.

Statutory authority: Section 1861(r)(4) optometrist recognition

Section 1861(r) of the Social Security Act defines the term "physician" for Medicare purposes. The statute lists five physician categories. The fourth, at Section 1861(r)(4), as originally enacted, provided:

"The term 'physician,' when used in connection with the performance of any function or action, means... (4) a doctor of optometry, but only for purposes of subsections (p)(1) and (s)(3), (4), and (13) of this section and with respect to a beneficiary entitled to benefits under part B if such doctor performs the items or services on or after April 1, 1987, that he is legally authorized to perform as a doctor of optometry by the State in which he performs such items or services."

Later amendments broadened this recognition so that a doctor of optometry is a Medicare physician for the items and services described in subsection (s) that he or she is legally authorized to perform as an optometrist under state law.2

Several features deserve attention. First, optometrist recognition is more recent than recognition of other physician categories. Optometrists were not recognized as Medicare physicians from the original 1965 statute. Section 9337 of the Omnibus Budget Reconciliation Act of 1986 (Public Law 99-509) added optometrist recognition to Medicare. The expansion reflected congressional recognition that optometrists could deliver many ocular services at lower cost than ophthalmologists.2

Second, the recognition is conditional on state licensure scope. A Georgia O.D. can perform Medicare services that the State of Georgia authorizes an O.D. to perform. Georgia has progressively expanded optometric scope, most recently through SB 153. Georgia O.D.s can:

• Diagnose and treat eye diseases
• Prescribe topical and oral medications (including controlled substances for specific eye conditions)
• Perform certain laser procedures with appropriate credentialing
• Provide pre- and post-operative cataract care
• Manage glaucoma medically

Some advanced surgical procedures (cataract extraction, retinal surgery, corneal transplant) remain in ophthalmologist scope.

Third, the optometric recognition is more limited than for M.D.s and D.O.s. As first enacted it cross-referenced only specific subsections of the statute, and optometrists are not inpatient hospital physicians the same way M.D.s, D.O.s, podiatrists, dentists, and chiropractors are recognized.

Fourth, the statute is silent on the routine eye examination exclusion. That exclusion appears in Section 1862, which we turn to next.

The exclusion: Section 1862(a)(7) and 42 CFR 411.15(b)

Section 1862 of the Social Security Act enumerates items and services that Medicare may not pay for. Subsection (a)(7) is the routine eye examination and eyeglasses exclusion:

"Notwithstanding any other provision of this title, no payment may be made under part A or part B for any expenses incurred for items or services... where such expenses are for routine physical checkups, eyeglasses (other than eyewear described in section 1861(s)(8)) or eye examinations for the purpose of prescribing, fitting, or changing eyeglasses, procedures performed (during the course of any eye examination) to determine the refractive state of the eyes, hearing aids or examinations therefor, or immunizations (except as otherwise allowed under section 1861(s)(10))..."

Three distinct exclusions are bundled together:

1. Routine physical checkups: General preventive physical examinations are excluded (although specific preventive services covered under Section 1861(ddd) and the Initial Preventive Physical Examination (IPPE) and Annual Wellness Visit (AWV) are now covered under separate authorities).

2. Eyeglasses: Standard eyeglasses for vision correction are excluded. The exception is the post-cataract eyewear under Section 1861(s)(8).

3. Routine eye examinations and refractions: Eye examinations performed for the purpose of prescribing, fitting, or changing eyeglasses are excluded. The refraction procedure (the part of an eye examination that determines the spectacle prescription) is excluded specifically.

The exclusion's structure means:

• A routine annual eye examination for glasses prescription is non-covered
• The refraction portion of any eye examination is non-covered (even when other components are covered)
• Standard eyeglasses or contact lenses for vision correction are non-covered
• Examinations performed because of an eye disease are covered as medically necessary care

42 CFR 411.15(b) implements the Section 1862(a)(7) exclusion. The regulation:

• Defines routine eye examination as an examination whose primary purpose is to assess and correct refractive error
• Establishes that refractions are non-covered regardless of the examination's other purposes
• Lists the specific exceptions (post-cataract eyewear under Section 1861(s)(8))
• Distinguishes routine eye care from medical eye care based on the documented purpose of the visit

The regulation's structural premise is that routine vision care is something most older adults can obtain through community-based optometric services on a fee-for-service basis. Medical eye care (disease evaluation, surgery, treatment) is the appropriate Medicare focus.3

Original Medicare does not cover routine eye exams for eyeglasses or contact lenses, but it does cover medically necessary eye care for disease, including cataract surgery, glaucoma testing and treatment, diabetic retinopathy exams, and age-related macular degeneration.4

The exception: Section 1861(s)(8) post-cataract eyewear

Section 1861(s)(8) of the Social Security Act establishes the post-cataract eyewear exception. The relevant statutory language:

"prosthetic devices (other than dental) which replace all or part of an internal body organ (including colostomy bags and supplies directly related to colostomy care), including one pair of conventional eyeglasses or contact lenses furnished subsequent to each cataract surgery with insertion of an intraocular lens..."

The IOL itself is a covered prosthetic device. Cataract surgery (CPT 66984, removal with IOL insertion) is among the most commonly performed surgical procedures in Medicare. Coverage includes:

• The cataract surgical procedure (CPT 66984 or CPT 66982 for complex cataract)
• The intraocular lens implanted during surgery (standard monofocal)
• One pair of conventional eyeglasses or contact lenses furnished after the surgery
• Pre-operative evaluation
• Post-operative care during the 90-day global period

The post-cataract eyewear coverage is specifically tied to conventional eyewear. Conventional means standard materials (single vision, bifocal, or trifocal lenses; standard frames). Premium or upgraded features (progressive lenses, anti-reflective coating, transition lenses, designer frames) are beneficiary responsibility above the conventional cost. The conventional benefit pays a defined amount; beneficiaries who upgrade pay the difference.

The benefit is one pair per cataract surgery. A beneficiary having cataract surgery on the right eye receives one pair of eyeglasses after that surgery. If the beneficiary later has cataract surgery on the left eye, a second pair is covered. Medicare's guidance states the exception in exactly those terms, one pair after each cataract surgery with an intraocular lens, and outside that exception you pay all costs for most eyeglasses or contact lenses.1

The supplier requirement that voids the benefit

One condition decides whether Medicare pays anything at all for that pair, and it is the one patients most often learn too late. Medicare "will only pay for contact lenses or eyeglasses from a supplier that participates in Medicare, whether you or your provider submits the claim."1 Take the post-operative prescription to whichever optical shop is convenient, and if that shop is not enrolled in Medicare you pay the entire cost. The one pair you were entitled to for that surgery is simply forfeited; there is no second pair until the other eye is operated on.1

The practical step is small and it has to happen first. Before you order the glasses, ask the optical shop whether it participates in Medicare, and if the answer is anything other than a clear yes, ask the surgeon's office which local supplier it bills through. Doing this after the lenses are cut is too late.

The benefit is administered through DMEPOS suppliers (the surgeon's optical shop, a separate optical dispenser, or another enrolled supplier). The supplier bills V-codes for the lenses and frames, with the appropriate modifiers indicating post-cataract status. Medicare pays 80 percent of the conventional approved amount after the deductible; the beneficiary owes 20 percent coinsurance.1

The exception: Section 1861(s)(10) and 42 CFR 410.23 glaucoma screening

Glaucoma screening became a covered Medicare benefit through Section 102 of the Benefits Improvement and Protection Act of 2000 (Public Law 106-554). The implementing regulation is at 42 CFR 410.23.2

The rationale for the glaucoma screening benefit reflected several observations. Glaucoma is a leading cause of irreversible blindness in older Americans. Glaucoma is asymptomatic until vision loss is advanced, by which time substantial damage has occurred. Early detection through screening allows treatment that preserves vision. Certain populations (diabetics, family history patients, Black Americans, Hispanic Americans) carry substantially higher risk. Screening these high-risk groups annually is cost-effective in preventing blindness.

Eligibility

Eligible beneficiaries (high-risk groups) under 42 CFR 410.23:

• Individuals with diabetes mellitus
• Individuals with a family history of glaucoma (typically first-degree relative)
• African Americans aged 50 years or older
• Hispanic Americans aged 65 years or older

Covered services

The covered glaucoma screening services include:

• Dilated eye examination with intraocular pressure measurement
• Direct ophthalmoscopy examination of the optic nerve
• Slit-lamp biomicroscopic examination

Frequency

Once every 12 months for eligible beneficiaries. The 12-month interval is measured between visits.

HCPCS codes

• G0117: Glaucoma screening for high-risk patients furnished by an optometrist or ophthalmologist
• G0118: Glaucoma screening for high-risk patient furnished under the direct supervision of an optometrist or ophthalmologist

Cost-sharing

Glaucoma screening was originally subject to the Part B deductible and 20 percent coinsurance. The screening is not classified as a "preventive service" under the Affordable Care Act's no-cost-sharing rules. Beneficiaries with Medigap typically have the coinsurance covered. Medicare Advantage plans may have different cost-sharing.2

The standard: annual diabetic eye examinations

Annual diabetic eye examinations are recognized as medically necessary eye care for diabetic patients, covered as standard Part B physician services rather than as a separate screening benefit.2 Diabetic eye examination is typically billed using standard ophthalmological examination codes with the diabetes diagnosis (ICD-10 E10 through E14, with retinopathy specifiers as appropriate). Common billing patterns:

• Comprehensive ophthalmological examination (CPT 92004 new patient or 92014 established patient)
• Intermediate ophthalmological examination (CPT 92002 or 92012)
• Fundus photography (CPT 92250) when clinically indicated for documentation or evaluation
• OCT retina (CPT 92134) when clinically indicated
• Visual field examination (CPT 92081-92083) when clinically indicated

The refraction portion remains non-covered regardless of the diabetes diagnosis. The medical eye examination components are covered with appropriate documentation of the diabetic eye disease evaluation purpose.

Standard of care is annual diabetic eye examination for all diabetic patients. The American Diabetes Association, American Academy of Ophthalmology, and American Optometric Association all support annual dilated eye examinations for diabetics. Some Medicare Advantage plans implement diabetic retinopathy screening as a HEDIS quality measure with no cost-sharing to the enrollee.

Cataract surgery: the highest-volume Medicare surgical procedure

Cataract surgery is among the most commonly performed Medicare surgical procedures. The procedure has become highly streamlined over the past three decades, transforming from inpatient hospital surgery requiring weeks of recovery to outpatient ASC surgery with same-day return to most activities.1

Medicare states the coverage with a local qualifier worth reading closely: Part B "may cover cataract surgery that implants conventional intraocular lenses, depending on where you live."1 That wording points at local coverage decisions rather than an automatic national yes. Georgia claims are administered by Palmetto GBA, the Medicare Administrative Contractor for Jurisdiction J, so a beneficiary with a question about their own procedure should confirm it with Palmetto GBA rather than assume the national description settles it.

Clinical indications

Cataract surgery is medically necessary when:

• The cataract causes visually significant impairment affecting function (driving, reading, daily activities)
• Glasses adjustments cannot adequately correct vision
• The patient's vision loss is significant enough to justify surgical risk

CMS does not specify a particular visual acuity threshold for cataract surgery, but clinical judgment must support medical necessity. Documentation typically includes:

• Vision testing demonstrating functional impairment
• Examination findings consistent with visually significant cataract
• Patient symptom report indicating impact on daily activities

Surgical workflow

A typical cataract surgery patient pathway:

1. Initial evaluation. Patient presents to optometrist or ophthalmologist with vision complaints. Examination demonstrates cataract.

2. Surgical consultation. Patient referred to (or seen by) ophthalmologist for surgical evaluation. Comprehensive examination, biometry (measurement for IOL calculation), discussion of options (conventional vs. premium IOL).

3. Surgical scheduling. ASC or hospital outpatient setting. Local or topical anesthesia with monitored anesthesia care.

4. Day-of-surgery. Phacoemulsification (ultrasound-assisted lens fragmentation and aspiration) with IOL insertion. Typical operative time 15 to 30 minutes per eye.

5. Post-operative care. Same-day discharge. Post-operative visits at day 1, week 1, week 4. Topical antibiotic and anti-inflammatory drops for 4 to 6 weeks.

6. Final refraction and eyewear. At 4 to 6 weeks post-op, when vision has stabilized. Final eyeglass prescription. Post-cataract eyewear ordered under Section 1861(s)(8) benefit.

Cost components

Cataract surgery involves three billing components: the surgeon fee (CPT 66984), the ASC facility fee (which includes the conventional monofocal IOL), and anesthesia. Medicare pays 80 percent of the approved amounts after the Part B deductible; the beneficiary owes 20 percent coinsurance, typically covered by Medigap.1

The 90-day global period bundles all post-operative care into the surgical fee. Post-operative visits within 90 days are not separately billed.

Premium IOL economics

Standard monofocal IOLs are bundled into the surgical facility fee. Premium IOLs cost more and are beneficiary responsibility for the upcharge:

• Toric IOL (corrects astigmatism): upcharge above conventional, beneficiary responsibility
• Multifocal IOL (corrects near and distance vision): upcharge above conventional, beneficiary responsibility
• Extended depth of focus (EDOF) IOL: upcharge above conventional, beneficiary responsibility
• Accommodating IOL: upcharge above conventional, beneficiary responsibility

Beneficiaries should understand that premium IOL upcharges are out of pocket and are not reimbursable by Medicare or by most Medigap policies. Premium IOLs may provide quality-of-life improvements (reduced dependence on glasses) but are not covered medical care. The conventional monofocal IOL provides excellent vision at one focal distance (typically optimized for distance), with reading glasses needed for near work.1

Post-cataract eyewear benefit detail

After cataract surgery with IOL implantation, the beneficiary is entitled to one pair of conventional eyeglasses or contact lenses under Section 1861(s)(8). The benefit:

• Includes lenses (single vision, bifocal, or trifocal based on the post-operative refraction)
• Includes a standard frame
• Pays for conventional materials at a defined Medicare allowable
• Beneficiary upgrades (progressive lenses, anti-reflective coating, designer frames, transition lenses) are out of pocket above the conventional benefit
• Pays nothing at all unless the supplier participates in Medicare, whether the beneficiary or the provider submits the claim1

Medicare pays 80 percent of the conventional approved amount for the post-cataract eyewear after the Part B deductible (often already met by the cataract surgery itself), and the beneficiary owes the remaining 20 percent, frequently covered by Medigap. In 2026 the Part B deductible is $283.5

Beneficiaries should order the post-cataract eyewear within a reasonable time after surgery. No specific deadline is set, but waiting more than several months may complicate the claim.

HCPCS coding for optometric services

Ophthalmological examination codes

These codes are covered when the visit purpose is medical eye disease evaluation. The same codes are non-covered when the visit is for routine vision check for eyeglasses prescription. Documentation must reflect the actual clinical purpose.

Diagnostic and imaging codes

These diagnostic tests are covered when associated with appropriate medical diagnoses (glaucoma, retinal disease, optic nerve disease, diabetic retinopathy).

Screening codes

Major surgical codes

Materials codes (V-codes)

V-codes are generally non-covered except in connection with post-cataract surgery under Section 1861(s)(8).

Part B drug codes for anti-VEGF

Wet age-related macular degeneration: anti-VEGF treatment

Age-related macular degeneration is one of the leading causes of vision loss in older adults. AMD has two forms: dry (atrophic, slowly progressive) and wet (neovascular, can cause rapid vision loss). Until 2006, no effective treatment existed for wet AMD. The introduction of anti-VEGF (vascular endothelial growth factor) drugs transformed AMD prognosis.

Diagnosing wet AMD

Wet AMD diagnosis involves:

• Dilated fundus examination
• OCT retina (CPT 92134) showing subretinal or intraretinal fluid
• Fluorescein angiography (CPT 92235) showing choroidal neovascularization with leakage
• Documentation of vision loss or distortion

Treatment regimen

Standard treatment approach:

• Initial loading: 3 to 4 monthly injections
• Transition to "treat-and-extend" protocol: interval extended as long as macula remains dry
• Maintenance: injection every 4 to 16 weeks based on response
• Lifetime treatment for most patients

Anti-VEGF drugs and costs

The approved amounts vary by drug. Key options:

• Aflibercept (Eylea): 2 mg per injection; one of the most commonly used agents
• Aflibercept high-dose (Eylea HD): 8 mg per injection; allows longer dosing intervals for some patients
• Ranibizumab (Lucentis): 0.5 mg per injection; original anti-VEGF agent for AMD
• Bevacizumab (Avastin): 1.25 mg per injection; off-label use at substantially lower cost, extensively employed by retina specialists
• Biosimilars: increasingly available with reduced cost (aflibercept-jbvf, ranibizumab-eqrn)

Procedure billing

Each injection visit typically bills:

• 67028 (intravitreal injection of pharmacologic agent)
• J-code for the drug (e.g., J0178 for aflibercept): drug-specific approved amount

Medicare pays 80 percent of the total approved amount after the deductible; the beneficiary owes 20 percent coinsurance, typically covered by Medigap.2

Annual cost burden

A typical wet AMD patient receives 6 to 10 injections per year per affected eye. Because the Part B drug cost for brand-name anti-VEGF agents is substantial, the 20 percent coinsurance can be significant for beneficiaries without Medigap.2

Without Medigap, the out-of-pocket burden of anti-VEGF treatment can be substantial. Beneficiaries facing high coinsurance may discuss switching from Eylea or Lucentis to Avastin with their retina specialist. Avastin is approved by FDA for cancer but used off-label for AMD at substantially lower cost with comparable outcomes for many patients.

Glaucoma diagnosis and management

Glaucoma is the second leading cause of irreversible blindness in older Americans. Open-angle glaucoma is the most common type. Effective treatment requires regular monitoring and treatment with eye drops, laser, or surgery.

High-risk groups

Eligible for G0117 annual glaucoma screening:

• Diabetics
• First-degree family history of glaucoma
• African Americans aged 50 and older
• Hispanic Americans aged 65 and older

Diagnosing glaucoma

Glaucoma diagnosis involves:

• Intraocular pressure measurement (tonometry)
• Visual field examination (CPT 92081-92083)
• OCT optic nerve (CPT 92133)
• Gonioscopy (CPT 92020)
• Fundus photography (CPT 92250) for documentation

Medical treatment

Eye drops are first-line treatment. Common categories:

• Prostaglandin analogs: latanoprost, travoprost, bimatoprost (once-daily)
• Beta blockers: timolol (twice-daily)
• Alpha agonists: brimonidine (two or three times daily)
• Carbonic anhydrase inhibitors: dorzolamide, brinzolamide (two or three times daily)
• Rho kinase inhibitors: netarsudil (once-daily)
• Combination drops: multiple agents in one bottle

These prescription drugs are covered under Part D, not Part B. Beneficiaries have copays per their plan formulary. Generic latanoprost is widely available and is typically among the lowest-cost generic drops on a Part D formulary.

Laser treatment

Selective laser trabeculoplasty (SLT, CPT 65855) is increasingly used as first-line treatment. Many patients can avoid or delay topical medications. SLT typically lasts 3 to 5 years and can be repeated.

Surgical treatment

For glaucoma refractory to medication and laser:

• Trabeculectomy (CPT 66170): traditional filtering surgery
• Drainage device implantation (CPT 66180): for advanced or complicated cases
• Minimally invasive glaucoma surgery (MIGS): newer procedures often combined with cataract surgery

All glaucoma surgical procedures are covered as medically necessary Part B services.

Ongoing monitoring

Glaucoma patients require regular monitoring:

• Visual field examination (CPT 92081-92083): typically annually for stable patients, more frequently for progressing patients
• OCT optic nerve (CPT 92133): typically annually
• Comprehensive eye examination (CPT 92014): typically every 3 to 6 months for stable patients
• Intraocular pressure measurement at each visit

All these monitoring services are covered Part B services with appropriate glaucoma diagnosis.2

The Georgia optometric landscape

Licensure and oversight

Georgia optometrists are licensed by the Georgia State Board of Optometry under O.C.G.A. §43-30. The Board:

• Issues and renews optometrist licenses (every two years)
• Approves continuing education requirements
• Reviews disciplinary matters and consumer complaints
• Maintains a public license registry accessible online

Contact information:

• Address: 237 Coliseum Drive, Macon, GA 31217
• Phone: 404-657-9019 (Professional Licensing Boards Division of the Georgia Secretary of State)
• Email: op_board@sos.ga.gov

Georgia has a large population of licensed optometrists practicing across the state. Optometrists practice in multiple settings:

• Private optometric practices (single-doctor or group)
• Optical retail chains (LensCrafters, Visionworks, Walmart Vision Center, Costco Optical, Pearle Vision)
• Hospital-affiliated practices
• Group practices alongside ophthalmologists
• Federally Qualified Health Centers and Rural Health Clinics
• VA medical facilities (for veteran care)

Distribution mirrors the population, with the highest concentration in metro Atlanta.

Georgia scope of practice and SB 153 (2021)

O.C.G.A. §43-30 and subsequent amendments define the scope of Georgia optometric practice. Georgia has progressively expanded optometric scope over the past four decades:

• Pre-1980s: refraction and dispensing of corrective lenses
• 1980s and 1990s: addition of diagnostic agents (eye drops to dilate pupils, topical anesthetics)
• 1990s and 2000s: therapeutic agents (treatment of eye infections, allergies, glaucoma drops)
• 2010s: oral medications including controlled substances for specific eye conditions
• SB 153: expanded scope to include certain laser procedures, foreign body removal, and additional therapeutic procedures (with credentialing requirements)

Georgia O.D.s can:

• Diagnose and treat eye diseases including glaucoma, AMD, diabetic eye disease, dry eye syndrome, corneal disease
• Prescribe topical and oral medications including controlled substances for specific eye conditions
• Perform certain laser procedures with appropriate credentialing
• Provide pre- and post-operative cataract and ocular surgical care
• Manage glaucoma medically and through laser

Cataract extraction, retinal surgery, corneal transplantation, and other advanced surgical procedures remain in ophthalmologist scope. The expanded optometric scope allows many Medicare beneficiaries to access primary eye care from optometrists at potentially lower cost.

Georgia Optometric Association

The Georgia Optometric Association (770-961-9866) is the state professional society. GOA:

• Advocates for optometric interests at the General Assembly
• Provides continuing education programs
• Maintains a member directory accessible to the public
• Publishes clinical and practice management guidance

Palmetto GBA Jurisdiction J

Palmetto GBA processes Medicare Part B claims for Georgia, Alabama, and Tennessee. For optometry, Palmetto GBA's Local Coverage Determinations and policy articles address:

• Documentation standards for routine versus medical eye examinations
• Coverage of diagnostic testing (visual fields, OCT, fundus photography)
• Coverage of glaucoma screening
• Coverage of post-cataract eyewear
• Anti-VEGF drug coverage

Providers can contact Palmetto GBA at 1-877-567-9230.

Worked example #1: Margaret 76 Atlanta diabetic eye exam

The four worked examples below are hypothetical illustrations, not real individuals; actual costs depend on your plan, provider, and the Medicare-approved amounts.

Margaret is a 76-year-old in Atlanta with Type 2 diabetes for 12 years. Her primary care physician at Piedmont Healthcare recommends annual diabetic eye examination. She schedules with an optometrist at Emory Eye Center.

The examination:

• Comprehensive ophthalmological examination (CPT 92014)
• Fundus photography (CPT 92250) for documentation
• Discussion of findings and follow-up

The optometrist documents:

• Diabetes mellitus Type 2 with ICD-10 E11.9 (without complications) or E11.319 (with unspecified retinopathy if findings present)
• Examination findings: no retinopathy detected in this scenario
• Plan: annual follow-up

Billing:

• 92014 (comprehensive ophthalmological exam, established patient): covered
• 92250 (fundus photography): covered
• Refraction (separately billed, NOT covered): billed to Margaret at the practice's self-pay rate

Margaret has met her 2026 Part B deductible, so Medicare covers the medical eye exam components at 80 percent of the approved amount. Her 20 percent coinsurance is picked up by her Medigap Plan G, leaving nothing to pay for the covered services.2

Margaret's only out-of-pocket cost is the refraction, which the practice bills directly because it is statutorily non-covered.

The medical eye examination is fully covered because of the diabetes diagnosis. The refraction is statutorily non-covered regardless of the patient's medical conditions. Margaret is glad to have learned in advance that the refraction would not be covered (the optometrist's billing staff explained this before the visit).

Worked example #2: Robert 80 Savannah cataract surgery

Robert is an 80-year-old in Savannah with bilateral cataracts. His ophthalmologist at Memorial Health confirms visually significant nuclear sclerotic cataracts bilaterally affecting his ability to drive at night. They plan right-eye-first cataract surgery, with left-eye surgery 4 weeks later.

Right eye surgery

At an ASC in Savannah:

Billing components:

• Surgeon fee (CPT 66984)
• ASC facility fee (includes the conventional monofocal IOL)
• Anesthesia (monitored anesthesia care by anesthesiologist)

Robert has met his deductible. Medicare pays 80 percent of the approved total. Robert's 20 percent coinsurance is covered by Medigap Plan G, so he pays nothing for the surgery itself.1

Robert was offered a toric IOL upgrade (he has astigmatism). The toric IOL would have added an out-of-pocket upcharge. Robert chose the conventional monofocal IOL and plans to use eyeglasses for any residual astigmatism after surgery.

Post-cataract eyewear

Four to six weeks post-op, Robert's vision has stabilized. He undergoes final refraction at the optical shop affiliated with his ophthalmologist's practice, and he asks the shop one question before he orders anything: does it participate in Medicare? It does, which is what makes the claim payable at all.1 The optician fits him with:

• Single vision distance lenses + bifocal addition (reading)
• Standard plastic frames

Post-cataract eyewear billing under Section 1861(s)(8):

• V-codes for bifocal lenses and frame
• Modifier indicating post-cataract status

Medicare pays 80 percent of the conventional approved amount. Robert's 20 percent coinsurance is covered by Medigap.1

Robert chose NOT to upgrade to progressive lenses, anti-reflective coating, or designer frames (which would have added an out-of-pocket upgrade cost).

Left eye surgery and second pair of eyewear

Four weeks after the right-eye surgery, the left-eye surgery follows the same pattern. After the left-eye surgery, Robert is entitled to a second pair of post-cataract eyewear.

The benefit transformed Robert's vision from significantly impaired to functional, and the Medicare cost is modest compared to the lifetime functional value. This is the structure Section 1861(s)(8) was designed to support: comprehensive coverage of cataract surgery with conventional IOL plus the eyewear necessary to optimize post-cataract vision.

Worked example #3: Linda 73 Macon glaucoma screening

Linda is a 73-year-old African American woman in Macon. As an African American aged 50 and older, she is in a high-risk group for glaucoma. Her primary care physician at Atrium Health Navicent recommends annual glaucoma screening. She schedules with an optometrist.

The optometrist documents Linda's high-risk status (African American aged 50+) and conducts the screening:

• Dilated eye examination
• Intraocular pressure measurement (Goldmann applanation tonometry)
• Optic nerve examination (direct ophthalmoscopy)
• Slit-lamp biomicroscopic examination

Billing:

• G0117 (glaucoma screening, high-risk, by optometrist)

Linda has met her deductible. Medicare pays 80 percent of the approved amount. Linda's 20 percent coinsurance is covered by Medigap, so she pays nothing.2

In this scenario the screening is normal. Linda is scheduled for annual rescreening.

If the screening had identified abnormal findings (elevated IOP, suspicious optic nerve, narrow angles), the optometrist would have ordered additional diagnostic testing as medically necessary, billed separately under standard CPT codes with appropriate glaucoma-suspect diagnoses. Annual screening continues regardless.

Worked example #4: Charles 78 Augusta routine eye exam

Charles is a 78-year-old in Augusta who wants new eyeglasses. His current glasses are 3 years old, and he notices his vision is changing. He visits an optometrist at a private practice for a routine eye examination.

The optometrist explains the coverage rules:

• Charles has no diabetes, no glaucoma diagnosis, no qualifying medical eye condition
• A routine eye examination for the purpose of prescribing glasses is statutorily excluded under Section 1862(a)(7)
• The refraction is statutorily excluded regardless of any other coverage

The optometrist provides an Advance Beneficiary Notice (ABN, CMS form R-131). Charles signs the ABN acknowledging financial responsibility.

The examination:

• Comprehensive ophthalmological examination (CPT 92004)
• Refraction
• Eyeglass prescription provided

The optometrist bills 92004 with the GA modifier (ABN on file). Medicare denies the claim as routine, and Charles pays the practice's self-pay rate for the examination plus a separate charge for the refraction.

Charles then visits the practice's optical department to order new glasses. He selects:

• Progressive lenses (for both distance and reading)
• Anti-reflective coating
• Designer frame

The upgraded lenses and frame are also entirely out of pocket, so between the self-pay examination, the refraction, and the premium eyewear, Charles pays for the entire visit himself.

If Charles had a Medicare Advantage plan with vision benefits, much of this cost might have been covered, since many MA plans include a routine eye exam at a low copay plus a frame-and-lens allowance. He has Original Medicare with Medigap Plan G, which provides no vision benefits.

Charles considers switching to Medicare Advantage during the next Annual Enrollment Period (October 15 through December 7) to gain vision benefits. He calls GeorgiaCares SHIP (1-866-552-4464) to discuss the trade-offs (network restrictions, prior authorization, premium changes). After consultation, Charles decides to stay with Original Medicare plus Medigap and budget for out-of-pocket vision care.6

Fourteen common mistakes in Medicare optometry coverage

Mistake one: assuming routine eye exams are covered

Many beneficiaries assume Medicare covers an annual eye examination for vision check. In fact, routine eye examinations for the purpose of prescribing or changing eyeglasses are excluded under Section 1862(a)(7) and 42 CFR 411.15(b). Beneficiaries who want annual vision checks for glasses must pay out of pocket or use Medicare Advantage supplemental vision benefits.

Mistake two: confusing routine eye exam with medical eye exam

The same provider performing the same examination uses different documentation and billing depending on clinical purpose. A "routine" eye exam (for glasses) is non-covered. A "medical" eye exam (evaluating diabetes, glaucoma, AMD, dry eye, or other eye disease) is covered. If a patient with diabetes schedules with an optometrist for a diabetic eye examination, the visit is covered. If the same patient schedules a visit "to get new glasses" with the same optometrist, the visit is non-covered.

Mistake three: assuming Medicare covers regular eyeglasses

Standard eyeglasses for vision correction are non-covered. The exception is the one pair of post-cataract eyewear after cataract surgery with IOL under Section 1861(s)(8). Beneficiaries who need glasses for general vision correction must pay out of pocket or use Medicare Advantage supplemental benefits (many MA plans include an annual frame allowance).

Mistake four: not understanding the post-cataract eyewear benefit

The post-cataract eyewear benefit covers one pair of conventional eyeglasses or contact lenses per cataract surgery. The costliest version of this mistake is filling the prescription at a shop that does not participate in Medicare: Medicare then pays nothing, whoever submits the claim, and that surgery's one pair is gone.1 Beneficiaries should:

• Order the eyewear after vision has stabilized (typically 4 to 6 weeks post-op)
• Confirm the supplier participates in Medicare before ordering (the surgeon's optical shop or another enrolled optical provider)
• Understand the conventional limit (upgrades to progressive lenses, anti-reflective coatings, designer frames cost extra)
• Order before too much time has passed (no specific deadline, but reasonable timing expected)

Mistake five: thinking premium IOLs are covered

Standard monofocal IOLs are covered (bundled in the cataract surgery payment). Premium IOLs (toric, multifocal, accommodating, EDOF) are NOT covered above the conventional cost. Beneficiaries who choose premium IOLs pay the upcharge out of pocket. The upcharge is not reimbursable by Medicare or by most Medigap policies.

Mistake six: not getting glaucoma screening when eligible

Eligible high-risk beneficiaries (diabetics, family history, African Americans aged 50+, Hispanic Americans aged 65+) qualify for annual glaucoma screening (HCPCS G0117). Many beneficiaries are unaware of this benefit. They should ask their optometrist or ophthalmologist about the screening, especially those in the high-prevalence groups.

Mistake seven: assuming all anti-VEGF drugs cost the same

Aflibercept (Eylea) and ranibizumab (Lucentis) carry substantial per-injection costs as brand-name Part B drugs. Bevacizumab (Avastin), used off-label for AMD, costs far less per injection. Clinical outcomes are comparable for many patients. Beneficiaries facing 20 percent coinsurance on years of anti-VEGF treatment without Medigap should discuss cost-effectiveness with their retina specialist.2

Mistake eight: not coordinating with Medicare Advantage vision benefits

Many Medicare Advantage plans include vision benefits as supplemental coverage: annual routine eye examination, annual frame allowance, lens coverage, contact lens coverage. Beneficiaries with MA vision benefits should use them. Coverage is typically provided through a separate vision network (VSP, EyeMed) that may not include all optometrists.

Mistake nine: missing the diabetic retinopathy screening

Annual diabetic eye examinations are standard of care for all diabetic patients. Medicare covers these examinations under standard physician services with the diabetes diagnosis. Beneficiaries with diabetes should schedule annual eye exams. Failure to detect retinopathy early can result in permanent vision loss that timely treatment could have prevented.

Mistake ten: not understanding refraction billing

The refraction portion of an eye examination is statutorily non-covered (Section 1862(a)(7)). Even when a beneficiary has a medical eye examination (for glaucoma, diabetes, or other condition), the refraction component is separately billed and typically not covered by Medicare. Beneficiaries may see a separate refraction charge on their bill. This is normal and expected.

Mistake eleven: choosing an out-of-network optometrist for MA vision benefits

Medicare Advantage vision benefits are typically administered through a specific vision network (VSP, EyeMed, or other). Choosing an out-of-network optometrist may result in much higher out-of-pocket costs or no coverage at all. Beneficiaries should verify network participation before scheduling.

Mistake twelve: missing the difference between optometrist and ophthalmologist

Optometrists (O.D.) and ophthalmologists (M.D./D.O. with ophthalmology training) are both Medicare-recognized providers. Optometrists provide most primary eye care including refraction, glaucoma management, diabetic eye examination, and dry eye management. Ophthalmologists perform surgical procedures (cataract surgery, retinal surgery, corneal surgery) and may also provide primary eye care. Coordination between optometrist and ophthalmologist is common for cataract patients.

Mistake thirteen: not understanding the 90-day global period for cataract surgery

Cataract surgery has a 90-day global period under Medicare. This means post-operative visits within 90 days are bundled into the surgical fee and not separately billed. Beneficiaries should not be surprised to receive multiple post-operative visits without additional billing during this period.

Mistake fourteen: confusing low vision rehabilitation with routine vision care

Low vision rehabilitation services (for patients with significant vision loss not correctable by glasses or surgery) may be covered as physical or occupational therapy services under different rules. This is distinct from routine vision care and is covered for patients with severe vision impairment that affects daily function.

Coordination with Medicare Advantage

Many Medicare Advantage plans include vision benefits beyond what Original Medicare covers:

• Annual routine eye examination: typically a low or no copay
• Annual frame allowance: a fixed dollar allowance toward eyeglass frames
• Lens coverage: single vision, bifocal, progressive (with possible additional coatings)
• Contact lens allowance: alternative to eyeglass benefit
• Premium IOL coverage: some plans cover or subsidize premium IOLs
• Vision network: typically administered through VSP, EyeMed, or other vision network

Beneficiaries with significant vision care needs may benefit substantially from MA vision benefits. Specific benefit structure varies by plan, year, and county.4

GeorgiaCares SHIP (1-866-552-4464) provides free Medicare plan comparison counseling. Beneficiaries should ask specifically about vision benefits when comparing plans during the Annual Enrollment Period (October 15 through December 7).6

Coordination with Medicaid for dual-eligible beneficiaries

Georgia Medicaid covers limited vision services for adults under specific medical necessity rules. For dual-eligible Medicare-Medicaid beneficiaries, the Qualified Medicare Beneficiary (QMB) program, one of the Medicare Savings Programs, pays Medicare premiums, deductibles, and coinsurance for enrollees within the 2026 income and asset limits.7

• Medicare cost-sharing is covered by Georgia Medicaid (via the QMB program), resulting in no out-of-pocket cost for Medicare-covered services
• Medicaid may cover additional vision services not covered by Medicare (one pair of basic eyeglasses per period, depending on Medicaid program)
• Specific Medicaid vision coverage for adults is more limited than for children

Contact Georgia DCH Medicaid Member Services at 1-866-211-0950 for current Medicaid vision benefit details.8

How to access Georgia Medicare optometry services: finding a participating optometrist

Several pathways help Georgia beneficiaries identify participating optometrists:

• Medicare's Care Compare tool at medicare.gov/care-compare lists Medicare-enrolled providers by specialty, location, and accepting status. Search by "optometrist" and Georgia zip code.

• The Georgia Optometric Association (770-961-9866) maintains a public referral resource for member optometrists.

• The Georgia State Board of Optometry (404-657-9019) maintains the public license registry.

• Medicare Advantage plan provider directories for MA enrollees, available through the plan's website or member services line.

• Primary care physician referral, especially for diabetic patients (the primary care physician often has working relationships with optometrists experienced in diabetic eye examination).

• Optical retail chain locator tools for chains with multiple Georgia locations.

When selecting an optometrist, beneficiaries should ask:

• Does the practice accept Medicare assignment?
• Is the practice in-network for my Medicare Advantage plan (if applicable)?
• Does the practice routinely perform diabetic eye examinations and glaucoma screening?
• Does the practice have arrangements with optical providers for post-cataract eyewear (for cataract patients)?
• Does the practice coordinate care with my primary care physician?

Appeals and disputes

When Medicare denies an optometric claim, beneficiaries have access to the five-level Medicare appeals process:

For optometric claim denials, common issues involve:

• Disputed coverage of routine versus medical eye examination (was the documentation clear about medical necessity?)
• Disputed coverage of diagnostic testing (was the testing medically necessary for the documented condition?)
• Disputed coverage of post-cataract eyewear (was the eyewear within the conventional benefit?)
• Disputed coverage of anti-VEGF drugs (was the drug appropriately administered and documented?)

The Medicare Rights Center (1-800-333-4114) and the Center for Medicare Advocacy (1-860-456-7790) provide free guidance on appeals. Atlanta Legal Aid Society (404-377-0701) and Georgia Legal Services Program (1-800-498-9469) provide free legal assistance to qualifying low-income beneficiaries.8

At Brevy, we help Georgia families understand Medicare eye care coverage

At Brevy, we publish trustworthy, comprehensive eldercare guides for American families. Our goal is to help Georgia Medicare beneficiaries, their adult children, and the clinicians who care for them understand how Medicare's complex coverage rules work in practice. This guide on Medicare optometry services is part of a broader Georgia Medicare Part B series at brevy.com that covers physician services, preventive services, podiatry services, chiropractic services, ambulatory surgical centers, outpatient hospital services, rural health clinics, and many other benefit categories. We update our guides regularly as CMS issues new policy and as fee schedules, deductibles, and other thresholds change.

This guide is informational and does not constitute medical, legal, or financial advice. For specific coverage questions about your situation, contact 1-800-MEDICARE, your Medicare Administrative Contractor (Palmetto GBA at 1-877-567-9230 for Georgia), GeorgiaCares SHIP (1-866-552-4464), the Medicare Rights Center (1-800-333-4114), or a qualified Medicare counselor or attorney. For specific medical questions, consult your optometrist, ophthalmologist, or primary care physician.6

Find personalized help navigating Medicare eye care coverage in Georgia at brevy.com.

Georgia optometry and Medicare contacts

Learn More

Brevy helps Georgia families understand how Medicare covers eye care so they know what to expect before the appointment, not after the bill arrives.

The information on Brevy.com is for educational purposes only and is not a substitute for professional legal, financial, or medical advice. Rules vary by state and program and change frequently. Always verify with the relevant agency or a qualified professional. Brevy is not a law firm, financial advisor, or healthcare provider.