Benefits for Nonsurgical Vision Services to Change for Texas Medicaid January 1, 2016

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1 Benefits for Nonsurgical Vision Services to Change for Texas Medicaid January 1, 2016 Information posted November 20, 2015 Note: All new and updated procedure codes and their associated reimbursement rates are proposed benefits pending a rate hearing and approval of expenditures. Providers will be notified when the rates and expenditures are approved. Note: This article applies only to claims submitted to TMHP for processing. Refer to the Medicaid managed care organizations (MCOs) for information about MCO benefits, limitations, prior authorization, reimbursement, and MCO specific claim processing procedures. Effective for dates of service on or after January 1, 2016, benefits for nonsurgical vision services will change Texas Medicaid. Examinations Limitations for routine eye examinations with refraction testing for the purpose of obtaining eyeglasses will no longer be based on fiscal years. New limitations will be as follows: Clients who are birth through 20 years of age are eligible for a routine eye examination with refraction testing for the purpose of obtaining eyeglasses once every 12 months. Clients who are 21 years of age and older are eligible for a routine eye examination with refraction testing for the purpose of obtaining eyeglasses once every 24 months. Procedure codes 92002, 92004, 92012, 92014, and will no longer be diagnosis restricted. Procedure codes 92002, 92004, 92012, and are limited to one service per day, any Clients with a vision impairment that may require intensive or comprehensive vision impaired related services should be referred to the Department of Assistive and Rehabilitative Services (DARS). Procedure codes S0620 and S0621 will be denied if billed with the same date of service as procedure code Contact Lenses A contact lens fitting for the placement of a corneal bandage lens may be medically necessary for eye protection and pain control due to a disease process or injury. Procedure code will be limited to once per eye when it is billed by any When procedure code is performed on both eyes on the same date of service, one procedure may be reimbursed at the full rate and the second procedure may be reimbursed at half rate. Procedure code will be limited to one service per lifetime when billed by the same Procedure code will be denied if billed with the same date of service by the same provider as procedure code Nonprosthetic contact lenses for emergency placement do not require prior authorization. Documentation must be submitted with the claim.

2 Prior authorization will be required for all other contact lenses. Procedure code will be a benefit when provided by physician, nurse practitioner (NP), clinical nurse specialist (CNS), physician assistant (PA), optometrist, optician, and dispensing optical company providers for services rendered in the office or setting. Procedure code will no longer be diagnosis restricted. Special Ophthalmological Services The professional and technical components of procedure codes and will be benefits as follows: Type of Service (TOS) Place of Service Provider Types Component (TOS I) Technical Component (TOS T) Corneal topography (procedure code 92025) is considered medically necessary to diagnose, monitor, and treat various visual conditions such as, but not limited to the following: Corneal abrasion Corneal irregularities Corneal disease Corneal injury Keratoconus Procedure code will be limited to two per calendar year when billed by any provider, and it will no longer be diagnosis restricted. Procedure code will no longer be a benefit of Texas Medicaid. Gonioscopy Procedure code will be restricted to the following diagnosis codes: Diagnosis Codes H40001 H40002 H40003 H40011 H40012 H40013 H40021 H40022 H40023 H40031 H40032 H40033 H40041 H40042 H40043 H40051 H40052 H40053 H40061 H40062 H40063 H4010x0 H4010x1 H4010x2 H4010x3 H4010x4 H4011x0 H4011x1 H4011x2 H4011x3 H4011x4 H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H40141 H40142

3 H40143 H H H H H H H H H H H H H H H H4020x0 H4020x1 H4020x2 H4020x3 H4020x4 H40211 H40212 H40213 H H H H H H H H H H H H H H H H H40231 H40232 H40233 H40241 H40242 H40243 H4031x0 H4031x1 H4031x2 H4031x3 H4031x4 H4032x0 H4032x1 H4032x2 H4032x3 H4032x4 H4033x0 H4033x1 H4033x2 H4033x3 H4033x4 H4041x0 H4041x1 H4041x2 H4041x3 H4041x4 H4042x0 H4042x1 H4042x2 H4042x3 H4042x4 H4043x0 H4043x1 H4043x2 H4043x3 H4043x4 H4051x0 H4051x1 H4051x2 H4051x3 H4051x4 H4052x0 H4052x1 H4052x2 H4052x3 H4052x4 H4053x0 H4053x1 H4053x2 H4053x3 H4053x4 H4061x0 H4061x1 H4061x2 H4061x3 H4061x4 H4062x0 H4062x1 H4062x2 H4062x3 H4062x4 H4063x0 H4063x1 H4063x2 H4063x3 H4063x4 H40811 H40812 H40813 H40821 H40822 H40823 H4089 H409 H42 Q150 Ophthalmic Ultrasound Procedure codes 76510, 76511, 76512, 76513, 76516, and will no longer be diagnosis restricted, but they will be limited to two per calendar year when billed by any Ophthalmoscopy The professional and technical components of procedure codes 92235, 92240, and will be a benefit as follows: Type of Service (TOS) Place of Service Provider Types Component (TOS I) Technical Component (TOS T) Procedure codes 92225, 92226, 92230, 92235, and will be limited to one service per eye per day and two services per eye per calendar year when billed by any Procedure codes 92230, 92235, and must be billed with modifier LT or RT to identify the eye on which the service was performed. Procedure codes and will be limited to two per calendar year when billed by any Fundus photography is a benefit and is considered medically necessary when a clinical condition exists that is subject to change in extent, appearance or size and where such change

4 would directly affect the management of client care. These conditions include, but are not limited to, the following: Macular degeneration Glaucoma Hypertension Neoplasms of the retina Choroid (benign or malignant) Retinal hemorrhages Ischemia Retinal detachment Choroid disturbances Diabetic retinopathy Assessment of recently performed retinal laser surgery Fundus photography performed for a routine screen of a normal eye, in the absence of a clinical condition, that is subject to change in extent, appearance or size is not a benefit of Texas Medicaid. Ocular Viewing and Diagnostic Testing Procedures The following procedure codes will be limited to two per calendar year when billed by any Procedure Codes Procedure code will be limited to two services per calendar year when billed by any Procedure code will be considered for reimbursement as follows: The professional component must be billed with modifier LT or RT to identify the eye on which the service was performed. The technical component may be reimbursed once when one or both eyes are scanned on the same date of service by any The total component may be reimbursed with an additional professional service when both eyes are scanned on the same date of service by any The professional and technical components of the following procedure codes will be a benefit: Procedure Codes 92081, 92082, 92083, 92136, 92265, 92270, Type of Service (TOS) Place of Service Component (TOS I) Provider Types

5 92275, 92285, 92286, Technical Component (TOS T) Specialized Vision Services Procedure codes 92285, 92286, and will no longer be diagnosis restricted. For more information, call the TMHP Contact Center at