Section. CPT only copyright 2008 American Medical Association. All rights reserved. 45Vision Care (Optometrists, Opticians)

Transcription

1 Section 45Vision Care (Optometrists, Opticians) Enrollment Reimbursement Provider Responsibilities Benefits and Limitations Eye Examinations Refractive Errors Eye Examinations for the Purpose of Prescribing Eyewear Disease or Injury to the Eye Echography Corneal Topography Medicare/Medicaid Nonprosthetic Eyewear Dispensing Requirements Replacements Repairs Contact Lenses Noncovered Services/Supplies Nonprosthetic Eyeglasses and Contacts Frames Lenses Contact Lenses (Must be Prior Authorized) Contact Lens Services Not Covered Replacements Major Eyeglass Repairs Prosthetic Eyewear Medicare Coverage Replacements Significant Diopter Change Prosthetic Eyeglasses and Contacts Contact Lenses Eyeglasses SNF/ICF-MR Clients Claims Information Claim Filing Resources CPT only copyright 2008 American Medical Association. All rights reserved.

2 Section Enrollment To enroll in Texas Medicaid, optometrists (doctors of optometry [ODs]) must be licensed by the licensing board of their profession to practice in the state where the service is performed, at the time the service is performed, and be enrolled as Medicare providers. An optometrist cannot be enrolled if their license is due to expire within 30 days; a current license must be submitted. Important: All providers are required to read and comply with Section 1, Provider Enrollment and Responsibilities. In addition to required compliance with all requirements specific to Texas Medicaid, it is a violation of Texas Medicaid rules when a provider fails to provide health-care services or items to Medicaid clients in accordance with accepted medical community standards and standards that govern occupations, as explained in Title 1 Texas Administrative Code (TAC) (a)(6)(A). Accordingly, in addition to being subject to sanctions for failure to comply with the requirements that are specific to Texas Medicaid, providers can also be subject to Texas Medicaid sanctions for failure, at all times, to deliver health-care items and services to Medicaid clients in full accordance with all applicable licensure and certification requirements including, without limitation, those related to documentation and record maintenance. Refer to: Ophthalmology on page Provider Enrollment on page 1-3 for more information about enrollment procedures. Managed Care on page Reimbursement Professional services by an optometrist for contact lenses and prosthetic eyewear are reimbursed in accordance with 1 TAC , , and Federally Qualified Health Centers (FQHCs) are paid an allinclusive rate per visit for payable services in accordance with 1 TAC Suppliers of nonprosthetic lenses and frames are reimbursed the lesser of their billed amount or of the established maximum allowable fee in accordance with 1 TAC See the applicable fee schedule on the TMHP website at Refer to: Reimbursement Methodology on page 2-2 for more information about reimbursement. Vision on page D-36 for an example of the claim form Provider Responsibilities Suppliers of eyewear must comply with all Medicaid provider responsibilities and adhere to the following guidelines: Do not delay the ordering of eyewear or the dispensing of eyeglasses to the client while payment is pending from TMHP. Deliver the eyewear in a reasonable amount of time (usually two or three weeks from the date the order is placed by the client). Obtain the required eligibility information from the client s Medicaid Identification Form (Form H3087). Refer to the Eyeglasses column of the Medicaid Identification Form (Form H3087) to determine whether eyeglasses have been reimbursed by Medicaid within the last 24 months. Providers are advised to ask clients if they have recently received vision care services that may not appear on the Medicaid Identification Form (Form H3087) because of the delay in updating form information. Update the Eyeglasses column of the Medicaid Identification Form (Form H3087) to indicate that eyewear was dispensed. Initial, date, and mark the form to indicate that the service was performed. Temporary cataract lenses or glasses are payable during the four-month convalescent period even if the Medicaid Identification Form (Form H3087) does not have a check mark ( ) under the Eyeglasses column. However, the Medicaid Identification Form (Form H3087) must not have a check mark under the Eyeglasses column if nonprosthetic eyeglasses are to be obtained for use in conjunction with cataract contact lenses. Have the client or parent/guardian sign and date the Vision Care Eyeglass Patient (Medicaid Client) Certification Form and retain it in the providers records if the client selects eyewear that is not covered or if the client s eyewear is lost or destroyed. Have the client or parent/guardian sign and date the Vision Care Eyeglass Patient (Medicaid Client) Certification Form and retain in their records. Do not charge a Medicaid client more than a patient not enrolled in Medicaid for noncovered services (e.g., tints, oversized lenses, or frames). Keep invoices on file for a minimum of five years. Submit claims using the date eyeglasses were ordered as the date of service (DOS) (the start of the 95-day filing period), not the date the eyewear was dispensed Benefits and Limitations Eye Examinations In accordance with the Omnibus Budget Reconciliation Act (OBRA) of 1986, Section 9336, an optometrist is considered a physician within their scope of practice and certification level, with respect to the provision of any item 45 2 CPT only copyright 2008 American Medical Association. All rights reserved.

3 Vision Care (Optometrists, Opticians) or service the optometrist is authorized to perform by state law or regulation. Services by an optometrist are not limited to procedure codes S0620 and S0621. Texas Medicaid reimburses optometrists for eye examinations with refractions for diagnoses of refractive error, aphakia, and disease or injury of the eye Refractive Errors Procedure codes S0620 and S0621 are payable to optometrists when the diagnosis is diabetic retinopathy, refractive error, or corneal disorder related to contact lenses. Procedure code S0620 or S0621 is to be used by optometrists when billing for a Medicaid-only client and consists of preliminary diagnosis; analysis and complete diagnosis; and prescription and treatment. Claims for eye examination services require a diagnosis. If eyeglasses are not prescribed, diagnosis code V720 may be used. V720 must not be used on claims for eyewear. If the diagnosis is not known by the supplier of the eyewear, diagnosis code 3689 is acceptable. Claims for eye examinations that lack a diagnosis are listed as an incomplete claim on the Remittance and Status (R&S) report and must be resubmitted for payment consideration. Electronic claims that lack a diagnosis will be rejected. A letter with the reason for rejection and instructions for resubmission will be mailed the following business day. Procedure codes S0620 and S0621 are limited to the following diagnosis codes: V Eye Examinations for the Purpose of Prescribing Eyewear Refer to the Eye Exam column of the client s current Medicaid Identification Form (Form H3087) to determine if the client is eligible for an eye examination. Clients are eligible for new eyewear whenever there is a diopter change of 0.5 or more (old and new prescription must appear on the claim). Clients 20 years of age or younger are eligible for one examination with refraction for the purpose of obtaining eyewear during each state fiscal year (SFY) (September 1 to August 31, vision care annual periodicity schedule). The eye exam limitation can be exceeded for clients 20 years of age or younger, but only in the following situations: A school nurse, teacher, or parent requests the eye examination (identify this information in Block 9 of the CMS-1500 claim form) if medically necessary. Medically necessary (identify this information in Block 19 of the CMS-1500 claim form). Clients 21 years of age or older are eligible for one examination with refraction for the purpose of obtaining eyewear every 24 months. A new patient eye examination will be limited to one every 24 months, per client, per provider. A new patient eye examination in any place of service (POS) will be denied if the history shows that the same provider has furnished a medical service, a surgical service, or a consult within two years. Services billed as new patient eye examinations, procedure codes or 92004, in excess of this limitation will be denied. Eye examinations for aphakia and disease of or injury to the eye are not subject to any of the limitations listed above and are payable even if the Medicaid Identification Form (Form H3087) does not have a check mark ( ) under the Eye Exam column. If an office evaluation and management service or consultation is billed in addition to the eye examination by the same provider, the evaluation and management service or consultation will be denied as part of the eye exam. The following services are considered part of the office visit/eye examination reimbursement when performed on the same day: = Services payable to an FQHC based on an all-inclusive rate per visit. Note: Procedure code may be considered separately for reimbursement if it is used to bill Texas Medicaid for the refractive portion of an examination of clients who are eligible for both Medicare and Medicaid. The following services may be billed in addition to an office visit/eye examination: * * Procedure codes that are considered bilateral. = Services payable to an FQHC based on an all-inclusive rate per visit. Orthoptic and/or pleoptics training is considered part of the office visit, and is not separately payable. Office visits/eye examinations will be denied if billed with any of the following ophthalmology services on the same day: * 92260* 92265* 92270* 92275* 92285* 92286* 92287* * Procedure codes that are considered bilateral. = Services payable to an FQHC based on an all-inclusive rate per visit. 45 CPT only copyright 2008 American Medical Association. All rights reserved. 45 3

4 Section 45 The following procedure codes are payable to optometrists when accompanied by an appropriate diagnosis: S0620 S0621 = Services payable to an FQHC based on an all-inclusive rate per visit. In addition to optometric services, evaluation and management services and consultation codes (Table A) are payable to optometrists, when indicated, for the diagnoses in Table B. Table A: Evaluation and Management Services and Consultation Table B: Diagnosis Limitations CPT only copyright 2008 American Medical Association. All rights reserved.

5 Vision Care (Optometrists, Opticians) CPT only copyright 2008 American Medical Association. All rights reserved. 45 5

6 Section Procedure code S0620 or S0621 is payable with a diagnosis of refractive error only. Procedure code is not payable when billed with procedure code S0620 or S0621 on the same date of service. The following sonography procedures are payable to an optometrist when accompanied by an appropriate diagnosis: Procedure code is not a benefit and is considered as part of another procedure/service when billed on the same date of service by the same provider (e.g., Texas Health Steps [THSteps] visit or evaluation and management service) Disease or Injury to the Eye The following codes are payable to optometrists for the diagnosis of aphakia, disease of the eye, or injury of the eye: = Services payable to an FQHC based on an allinclusive rate per visit. Providers may not withhold from a client a prescription for eyeglasses pending Medicaid payment for the eye examination. Prescriptions for eyeglasses must be given to the client on request Echography Procedure codes 76510, 76511, 76512, and are payable for the following diagnoses or conditions: Procedure codes 76511, 76512, 76516, are payable for the following diagnoses: CPT only copyright 2008 American Medical Association. All rights reserved.

7 Vision Care (Optometrists, Opticians) Procedure code is payable for the following diagnoses: Procedure code 76511, 76516, or will not be reimbursed if procedure code is billed on the same day, by any provider Corneal Topography Corneal topography (procedure code 92025), is a benefit of Texas Medicaid and is subject to global surgery fee guidelines. An initial or established visit/consultation is payable on the same day as the topography. These visits remain subject to the global surgery fee guidelines. If topography is performed within the global surgical preand post-care days of the following ophthalmic procedures, the topography is denied as part of: Corneal topography is considered for reimbursement without prior authorization when submitted with any of the following diagnoses: V425 V4561 V4569 Services are payable to an FQHC based on an all-inclusive rate per visit. Procedure code must be prior authorized when used for the fitting of contact lenses (diagnosis codes 36720, and 74341). Prior authorization criteria must be met for both topography and for contact lenses. Procedure code may only be billed once per eye, per day, by any provider. Refer to: Contact Lenses on page 45-9 for contact lens information Medicare/Medicaid Eye examinations for the purpose of prescribing, fitting, or changing eyeglasses/contact lenses because of refractive errors are not a benefit of Medicare. These services must be filed directly to Medicaid when performed for a Medicare/Medicaid client. Medicare coverage is limited to eye examinations for treatment of eye disease or injury and for a diagnosis of aphakia. When performing an eye examination with refraction for a Medicare/Medicaid client diagnosed with aphakia or disease or injury to the eye, the following procedures must be followed: Procedure code must be used to bill Medicaid for the refractive portion of the examination and is payable with a diagnosis of aphakia or ocular disease only. The medical portion of the eye examination (92002, 92004, 92012, 92014) is covered by Medicare and must be billed to Medicare first. Medicare forwards this portion of the examination automatically to TMHP for payment of coinsurance and/or deductible. Important: Providers performing eye exams for refractive errors on STAR+PLUS clients (Medicaid Qualified Medicare Beneficiary [MQMB]) must bill TMHP, not the STAR+PLUS health plan. Provider must not send the refraction (92015) to Medicare first. Medicaid will not waive the 95-day filing deadline if the claim is billed to Medicare in error, nor will Medicare transfer the refraction to Medicaid for payment. 45 CPT only copyright 2008 American Medical Association. All rights reserved. 45 7

8 Section 45 Medicare allows payment of one pair of conventional eyewear (contact lens or glasses) for clients who have had cataract surgery with insertion of an intraocular lens (IOL). Medicare considers the IOL the prosthetic device. Medicaid providers must bill Medicare for the conventional (nonprosthetic) eyewear provided following an IOL insertion and bill Medicaid for any replacements of the conventional (nonprosthetic) eyewear using the procedure codes in the Nonprosthetic Eyeglasses and Contacts tables beginning on page Nonprosthetic Eyewear Eligible clients may receive nonprosthetic frames and/or lenses once every 24 months. This benefit period begins with the month the glasses are first dispensed. Refer to the Eyeglasses column of the client s Medicaid Identification Form (Form H3087) for determination of eligibility for this service. When there is a change in visual acuity (equal to or greater than 0.5 diopter in one eye), clients are eligible for new nonprosthetic eyeglasses, regardless of when they received their last pair of nonprosthetic eyeglasses or if their Medicaid Identification Form (Form H3087) does not have a check mark ( ) in the Eyeglasses column. Texas Medicaid provides for serviceable eyeglasses, contact lenses that are medically necessary and prior authorized, necessary major repairs to eyeglasses for clients who are 20 years of age or younger and replacement of lost/destroyed eyeglasses and contact lenses for clients who are 20 years of age or younger. Exception: Contact lenses for a diagnosis of aphakia do not require prior authorization. For clients who are 20 years of age or younger, there are no limitations on replacements for lost or destroyed eyewear. Eyewear will be reimbursed even if the client s Medicaid Identification Form (Form H3087) does not have a check mark ( ) in the services already rendered. Clients in Medicaid Managed Care health plans may be eligible for additional eyeglass benefits under their plan. Check with the client s health plan for details. Eyewear must be medically necessary and: Prescribed by a physician (doctor of medicine [MD], a doctor of osteopathy [DO]), or an optometrist (OD). Prescribed to significantly improve vision or correct a medical condition. Must meet the following eyeglass program specifications for frames and lenses: Frames Frames composed of all zynolite components. The frame is the entire piece of eyewear without the lenses. Frames composed of metal or a combination of zynolite and metal components for clients 20 years of age or younger. Combination frames for clients 21 years of age or older are reimbursed to the maximum allowable amount for a zynolite frame. The client may be billed the difference between the reimbursed amount and the billed amount, as the metal portion is not a benefit of the program for clients 21 years of age or older. All metal frames are not a benefit of Texas Medicaid for clients 21 years of age or older. Clients may be billed for frames that are beyond Medicaid benefits, as specified in Noncovered Services/Supplies on page American-made unless foreign-made frames are comparable in quality and are less expensive. Serviceable and able to meet statutory quality standards. Composed of new materials. Eyeglass Lenses Clear glass or plastic, including high-index plastics. Heat or chemically-treated dress eyewear able to meet standards of the American Standard Prescription Requirements for first quality glass and plastic lenses. Composed of new materials. A minimum kryptoc or 22 mm flat top lens or equivalent if bifocal. A minimum flat top 7/25 lens or equivalent if trifocal. The client must be eligible for Medicaid at the time the eyewear is dispensed Dispensing Requirements Providers must be able to dispense standard size frames at no cost to the eligible client. Providers must also show each eligible client a minimum of three styles of zylonite frames for male or female, child or adult, in a choice of three colors. The provider may also show combination frames of zylonite and metal. If the cost of frames exceeds the Medicaid maximum allowable fee, the client may be billed the difference of the billed amount. If there is no Medicaid coverage for the eyewear, the client is responsible for the entire amount. Clients must acknowledge their choice of eyewear beyond program limitations by signing the Vision Care Eyeglass Patient (Medicaid Client) Certification Form on page B Replacements Clients who are 20 years of age or younger may obtain replacements of nonprosthetic eyewear because of loss or destruction. Clients who are 21 years of age or older are not eligible for replacements because of loss or destruction of nonprosthetic eyewear. There is no limitation on the number of replacements a client who is 20 years of age or younger may receive. If eyewear is lost or destroyed, the provider must have the client sign the Vision Care Eyeglass Patient (Medicaid Client) Certification Form on page B-118. Replacement codes must be used to ensure accurate processing CPT only copyright 2008 American Medical Association. All rights reserved.

9 Vision Care (Optometrists, Opticians) Repairs Clients who are 20 years of age or younger may obtain repairs of nonprosthetic eyewear when the actual cost of materials exceeds $2. An invoice for the repair materials is not required to be submitted with the claim. Providers are required to maintain this information in the client s medical file and make it available for review by TMHP, HHSC, or the Attorney General s office when requested. The cost of repair supplies cannot exceed the amount that would have been payable, if the damaged eyewear had been a new purchase. All repair materials billed to Texas Medicaid must be new and at least equivalent to the original item. Repairs costing $2 or less are considered minor repairs. The eyeglass supplier is required to perform minor repairs on request (without charge) on eyewear that they have dispensed. Therefore, Texas Medicaid or the client may not be billed for any minor repairs. No benefits are allowed for repair of eyeglasses that do not meet the minimum program specifications or for clients who are eligible for Medicaid and are 21 years of age or older Contact Lenses Texas Medicaid allows reimbursement for contact lenses when no other option is available to correct a visual defect. Prior authorization is mandatory and must be received before dispensing the lens(es), unless the diagnosis is aphakia or when lenses are used as corneal bandages in an emergency. The emergency condition must be documented on the claim. Additionally, the client must be eligible for Medicaid at the time the lens(es) are dispensed. Providers must include the following information in each prior authorization request for contact lens(es): The client s name and Medicaid number, as they appear on the Medicaid card. The diagnosis causing the refractive error (for example, keratoconus). The current prescription (include the previous prescription if the request is because of a diopter change of 0.5 or more). The indication of the eye to be treated (right, left, or bilateral). The specific procedure code for contact lens(es) requested. A brief statement addressing the medical need for contact lens(es) (specify why eyeglasses are inappropriate or contraindicated for this client). The provider identifier. The signature of the physician or optometrist requesting prior authorization. Requests lacking this information will be denied. Mail or fax the request to the following address: Texas Medicaid & Healthcare Partnership Special Medical Prior Authorization B Riata Trace Parkway, Suite 150 Austin, TX Fax: Soft bandage plano lenses may be dispensed and billed to Texas Medicaid in an emergency situation without prior authorization. The claim must document the medical emergency. Replacement contact lenses are a benefit for lost or destroyed contact lenses for clients who are 20 years of age or younger when prior authorized by TMHP. Clients eligible for Medicaid may receive new nonprosthetic contact lenses when there is a significant change in visual acuity (equal to or greater than 0.5 diopter in one eye) and when prior authorized by TMHP. When billing for bilateral lenses, providers are to use the appropriate procedure code for unilateral lens and specify a quantity of 2 in Block 24E of the claim form. Refer to: Nonprosthetic Eyeglasses and Contacts on page Vision on page D-36 for an example of the claim form. Prosthetic Eyeglasses and Contacts on page Noncovered Services/Supplies The following services and supplies are not benefits of Texas Medicaid: All metal frames for clients 21 years of age or older (for example, frames with all metal structural components; plastic nose pieces or sheathing over ear pieces do not constitute a combination frame). Repairs and replacements of lost or destroyed eyewear for clients 21 years of age or older. Artificial eyes for clients 21 years of age or older. Plano sunglasses. Eyeglasses that do not significantly improve visual acuity or impede progression of visual problems. Eyewear prescribed or dispensed to clients at a hospital or nursing facility without documented orders of the attending physician in the client s medical records. Eyeglasses for residents of institutions where the reimbursement formula and vendor payment include this service. Optional eyeglass features requested by the client that do not increase visual acuity (e.g., lens tint, industrial hardening, decorative accessories, or lettering). Prisms that are ground into the lenses. Clients may be billed for noncovered frames and other items beyond Medicaid benefits. 45 CPT only copyright 2008 American Medical Association. All rights reserved. 45 9

10 Section 45 Providers must have the client sign and date the Vision Care Eyeglass Patient (Medicaid Client) Certification Form and retain it in the provider s records. The client payment amount is not considered other insurance and must not be entered as a credit amount in the electronic field. Example: The client wants oversized frames and tinted lenses for a total of $140 ($100 for frames, $30 for lenses, $10 for tinting). Medicaid pays $33.15 for the eyeglasses ($14.45 for the frames and $9.35 per lens, or $18.70 for both lenses). The client may be billed for the balance of the oversized frames ($85.55) plus the $10 charge for the tinted lenses. The provider may withhold the noncovered eyewear, contacts, or eyeglasses until the client pays for those items. If the client fails to pay for the noncovered items or has not returned for finished eyewear within a reasonable length of time (two to three months), the provider may return any reusable items to stock. Any payment made by TMHP for frames or lenses must be refunded to Texas Medicaid. If a client requests eyewear that is beyond program benefits (for example, all metal frames for clients 21 years of age or older), Medicaid allows reimbursement up to the maximum fee. The provider may charge the client the difference between the Medicaid payment and the customary charge for the eyewear requested, when the client has been shown the complete selection of Medicaid-covered eyewear and when the following conditions are met: The client rejects the Medicaid-covered eyewear and wants eyewear that complies with Texas Medicaid specifications, but is not included in the selection of Medicaid-covered eyewear. The client indicates a willingness to pay the difference between the Medicaid payment and the actual charge. The provider must have the client sign the Vision Care Eyeglass Patient (Medicaid Client) Certification Form and retain it in the provider s records. Providers who advertise two-for-one eyeglass special promotions without restrictions may not refuse the offer to clients with Medicaid coverage. For the purpose of Texas Medicaid, high-powered lenses are defined as those with a sphere greater than 7.00d or a cylinder greater than 4.00d. High-powered lenses are a benefit for clients who are 20 years of age or younger through THSteps-Comprehensive Care Program (CCP). for High-Powered Lenses V2102 V2105 V2106 V2109 V2110 V2111 V2112 V2113 V2114 V2202 V2205 V2206 V2209 V2210 V2211 V2212 V2213 V2214 V2302 V2305 V2306 V2309 V2310 V2311 V2312 V2313 V2314 Prior authorization is not required for high-powered lenses. The invoice is required and must be maintained in the provider s files. When billing on paper for these services, the invoice must be submitted with the claim and providers are to include a copy of the prescription and manufacturer s suggested retail price. Providers are to use the invoice cost as the billed amount and list the prescription on the claim form, indicating the power is greater than plus or minus 7 diopters or the cylinder is greater than plus or minus 4 diopters. The billed amount should not exceed the invoice amount. A client who experiences difficulty with daily living activities or employment related to vision may be referred to the Texas Department of Assistive and Rehabilitative Services (DARS). DARS can evaluate the client and may provide resources for assistance, as appropriate. Modifier RP must be used when billing for replacement lenses. When billing for an adult with diagnosis code 37931, modifier VP must also be billed. Refer to: The list of offices for the Department of Assistive and Rehabilitative Services (DARS), Blind Services on page A-16. The claim form example, Vision on page D-36. Nonprosthetic Eyeglasses and Contacts Nonprosthetic Eyeglasses and Contacts Frames Procedure Code V2020 V2025 Special Instructions Single vision eyeglasses (not high powered), procedure code V2020, should be billed with the lens codes in the table in Lenses on page Single vision eyeglasses (not high powered), with deluxe frames, procedure code V2025, should be billed with the lens codes in the table in Lenses on page V2025 must be used for nonprosthetic eyewear that is beyond program benefits Lenses Providers must use the following procedure codes when dispensing new lenses only (e.g., a client has 0.5 or greater diopter change requiring new lenses only). Providers are to bill a quantity of 2 for a pair of lenses. V2100 V2101 V2103 V2104 V2107 V2108 V2121 V2200 V2201 V2203 V2204 V2207 V2208 V2221 V2300 V2301 V2303 V2304 V2307 V2308 V CPT only copyright 2008 American Medical Association. All rights reserved.

11 Vision Care (Optometrists, Opticians) Contact Lenses (Must be Prior Authorized) Procedure Code V2500* V2501* V2502* V2510* V2511* V2512* V2513* V2520* V2521* V2522* V2523* V2530* V2531* V2599* *Use modifier VP for aphakic patients. Does not require prior authorization with a diagnosis of aphakia. Procedure code V2410 must be used in addition to a contact lens procedure code when billing for an aspheric contact Contact Lens Services Not Covered Procedure codes V2503 and are not covered Replacements Providers must use the appropriate procedure codes with modifier RP to indicate replacement when billing for lost or destroyed eyewear (only available for clients who are 20 years of age or younger). Bill the appropriate quantity of lenses. The client must sign and date the Vision Care Eyeglass Patient (Medicaid Client) Certification Form, and the provider must retain it in the provider's records. Refer to: Contact Lenses on page 45-9 for prior authorization information Major Eyeglass Repairs Providers billing for major eyeglass repairs should use procedure code V2799. This procedure will be manually priced Prosthetic Eyewear Prosthetic lenses replace the function of the eye s organic lens. Replacement may be necessary because of a defect or trauma resulting in aphakia (diagnosis code or 74335). However, the most frequent cause is surgical cataract extraction. The lenses can be contact lenses or eyeglasses. The date of cataract surgery is not required on claims for permanent prosthetic eyewear. The date of surgery is required to determine the convalescence period for temporary prosthetic eyewear. Contact lenses required as a postsurgical or congenital prosthetic may be supplied without prior authorization. Claims for temporary lenses are not payable, if dispensed after the four-month convalescence period. Claims for temporary eyewear that do not include the date of surgery are listed on the R&S as a claim in process and must be resubmitted for consideration of payment. Electronic claims of this type will be rejected. A letter with the rejection reason and instructions for resubmission will be mailed to the provider the following business day. Surgery dates on electronic claims must be identified in the appropriate fields of an approved electronic claims format. The name of the surgeon who performed the cataract surgery is not required on claims for postsurgical prosthetic eyewear. Texas Medicaid provides as many temporary prosthetic lenses (contacts or eyeglasses) as necessary during the postsurgical convalescence period (up to four months after surgery) and one pair of permanent prosthetic contact lenses or eyeglasses in a lifetime (exceptions include replacements and new prosthetic eyewear when there is a significant change in visual acuity) Medicare Coverage Postsurgical prosthetic cataract lenses are also a benefit of Medicare. If the client is eligible for Medicare coverage, the provider must bill Medicare first. Medicaid pays any deductible and/or coinsurance due. The provider must not require the client to pay the deductible and/or coinsurance Replacements Regardless of age, coverage is provided for the replacement of lost or destroyed prosthetic eyewear. Providers must use procedure code when billing for contact lenses replacement. For replacement of cataract eyewear frames or lenses, providers must use the appropriate cataract eyewear codes. The client must sign and date the Vision Care Eyeglass Patient (Medicaid Client) Certification Form, and the provider must retain it in the provider s records. Medicare allows payment of one pair of conventional eyewear (contact lens or glasses) for clients who have had cataract surgery with insertion of an IOL. Medicare and Medicaid consider the IOL the prosthetic device. Medicaid providers must bill Medicare for the conventional (nonprosthetic) eyewear provided following an IOL insertion and bill Medicaid for any replacements of the conventional (nonprosthetic) eyewear using the procedure codes from the Nonprosthetic Eyeglasses and Contacts tables beginning on page Significant Diopter Change Clients are eligible for new prosthetic eyewear when there is a significant change in visual acuity (equal to or greater than 0.5 diopter in one eye). The new prescription must be indicated in Block 24D, line 5, and the old prescription directly below it in Block 24D, line 6 of the CMS-1500 claim form. Prescription information for electronic claims must be in the electronic claims format. Providers must consult their vendor for the location of this field in the providers electronic format. The procedure codes listed for new eyewear must be used. Prior authorization is not required. 45 CPT only copyright 2008 American Medical Association. All rights reserved

12 Section Prosthetic Eyeglasses and Contacts Services for prosthetic eyewear must be billed with a diagnosis of aphakia (37931 or 74335) to be considered for reimbursement. Contact lenses require prior authorization unless billed with a diagnosis of aphakia Contact Lenses Providers must use the following codes when billing for prosthetic contact lenses: Procedure Code V2500 V2501 V2502 V2510 V2511 V2512 V2513 V2520 V2521 V2522 V2523 V2530 V2531 V2599 When temporary contact lenses are necessary after cataract surgery, submit the appropriate lens procedure code with diagnosis code V Eyeglasses Providers must use the following procedure codes when billing for prosthetic eyeglass frames and lenses (whether the lenses are glass or plastic): V2020 V2025 V2102 V2105 V2106 V2109 V2110 V2111 V2112 V2113 V2114 V2202 V2205 V2206 V2209 V2210 V2211 V2212 V2213 V2214 V2302 V2305 V2306 V2309 V2310 V2311 V2312 V2313 V2314 V2410 V2430 V2700 When prescribing bilateral lenses, providers are to use the appropriate code for a unilateral lens and specify a quantity of 2 in Block 24E of the claim form. When temporary eyeglasses are necessary after cataract surgery, submit the appropriate lens and frame procedure codes with diagnosis code V SNF/ICF-MR Clients Optometrist services provided in a skilled nursing facility (SNF) or intermediate care facility for the mentally retarded (ICF-MR) may be reimbursed by Texas Medicaid if the client s attending physician has ordered the service and the order is included in the client s medical records at the facility. Providers must document the physician s name and address or provider identifier in Block 17 of the CMS-1500 claim form. Claims submitted without this information are listed on the R&S as incomplete and must be corrected and resubmitted for consideration of payment. Electronic claims of this nature will be rejected. Attending physician information for electronic claims must be noted in the appropriate field of an approved electronic claims format Claims Information Vision care service claims must be submitted to TMHP in an approved electronic format or on a CMS-1500 paper claim form. Providers may purchase CMS-1500 claim forms from the vendor of their choice. TMHP does not supply the forms. When completing a CMS-1500 claim form, all required information must be included on the claim, as information is not keyed from attachments. Superbills, or itemized statements, are not accepted as claim supplements. When submitting the client's old and new prescriptions, enter the new prescription in Block 24D, line 5, and the old prescription in Block 24D, line 6 of the CMS-1500 claim form. Refer to: TMHP Electronic Data Interchange (EDI) on page 3-1 for information on electronic claims submissions. Claims Filing on page 5-1 for general information about claims filing. CMS-1500 Claim Filing Instructions on page Blocks that are not referenced are not required for processing by TMHP and may be left blank Claim Filing Resources Refer to the following sections and/or forms when filing claims: Resource Page Number Automated Inquiry System (AIS) xiii TMHP Electronic Data Interchange 3-1 (EDI) CMS-1500 Filing Instructions 5-26 TMHP Electronic Claims Submission 5-15 Communication Guide A-1 Vision Care Eyeglass Patient (Medicaid B-118 Client) Certification Form Vision Care Eyeglass Patient (Medicaid B-119 Client) Certification Form (Spanish) Vision claim form example D-36 Acronym Dictionary F CPT only copyright 2008 American Medical Association. All rights reserved.