Provider Handbooks. Vision and Hearing Services Handbook

Transcription

1 Provider Handbooks January 2016 Vision and Hearing Services Handbook The Texas Medicaid & Healthcare Partnership (TMHP) is the claims administrator for Texas Medicaid under contract with the Texas Health and Human Services Commission.

2 Table of Contents 1 General Information Payment Window Reimbursement Guidelines for Services Preceding an Inpatient Admission Nonimplantable Hearing Aid Devices and Related Services Enrollment School Districts, State Agencies, and Inpatient Facilities Services, Benefits, Limitations, and Prior Authorization Limitations and Required Forms Hearing Screenings Routine Hearing Screenings Additional Hearing Screenings Abnormal Hearing Screening Results Audiology and Audiometry Evaluation and Diagnostic Services Otological Examinations Vestibular Evaluations Forms and Documentation Prior Authorization Limitations SHARS Audiology Services Noncovered Services Hearing Aid Devices and Accessories (Nonimplantable) Forms and Documentation Prior Authorization Limitations Hearing Aid Services Forms and Documentation Prior Authorization Limitations Documentation Requirements Claims Filing and Reimbursement Claims Filing Non-implantable Hearing Aid Devices Third Party Liability Reimbursement National Correct Coding Initiative (NCCI) and Medically Unlikely Edit (MUE) Guidelines Implantable Hearing Devices and Related Services Enrollment Services, Benefits, Limitations and Prior Authorization Cochlear Implants Prior Authorization Limitations Auditory Rehabilitation Auditory Brainstem Implant (ABI) Prior Authorization Limitations Bone-Anchored Hearing Aid (BAHA)

3 Prior Authorization Limitations Sound Processor Replacement and Repair Prior Authorization Limitations Electromagnetic Bone Conduction Hearing Device - Removal Only Documentation Requirements Claims Filing and Reimbursement Claims Filing Third Party Liability Reimbursement NCCI and MUE Guidelines Vision Care Professionals Enrollment Provider Responsibilities Services, Benefits, Limitations, and Prior Authorization Services Performed in Long-Term Care Facilities Services Performed in Federally Qualified Healthcare Centers (FQHC) THSteps Medical Checkup Vision Screening Vision Screening Outside of a THSteps Preventive Care Medical Checkup Noncovered Services Vision Testing Routine Vision Testing Medically Necessary Eye Examinations Ophthalmological Examination and Evaluation with General Anesthesia Ophthalmic Ultrasound Corneal Topography Sensorimotor Examination Orthoptic or Pleoptic Training Ophthalmoscopy, Angioscopy or Angiography Other Professional Services Vision Services for Nonprosthetic Eyewear Eyeglass Lenses and Frames Contact Lens and Corneal Bandage Dispensing Requirements Repair Replacement Medicare Coverage for Nonprosthetic Eyewear Vision Services for Prosthetic Eyewear Temporary Eyeglasses or Contact Lenses Contact Lens Fitting and Modification Repair Replacement Intraocular Lens (IOL) and Additional Eyewear Artificial Eyes Ultraviolet (U-V) Protection Surgical Vision Services Documentation Requirements

4 4.5 Claims Filing and Reimbursement Claims Filing Reimbursement NCCI and MUE Guidelines Claims Resources Contact TMHP Forms Claim Form Examples

5 1 General Information The information in this handbook is intended for optometrists (doctors of optometry), ophthalmologists, and opticians who render services related to the eye and vision and for hearing aid professionals (fitters and dispensers, physicians, and audiologists) who provide hearing evaluations or fitting and dispensing services. The handbook provides information about Texas Medicaid s benefits, policies, and procedures applicable to these providers. Important: All providers are required to read and comply with Subsection 4.1, Enrollment. 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 healthcare 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) 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 healthcare 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: Section 1: Provider Enrollment and Responsibilities (Vol. 1, General Information). This handbook contains information about Texas Medicaid fee-for-service benefits. For information about managed care benefits, refer to the Medicaid Managed Care Handbook (Vol.2, Provider Handbooks). Managed care carve-out services are administered as fee-for-service benefits. A list of all carve-out services is available in Section 8, Carve-Out Services in the Medicaid Managed Care Handbook (Vol. 2, Provider Handbooks). 1.1 Payment Window Reimbursement Guidelines for Services Preceding an Inpatient Admission According to the three-day and one-day payment window reimbursement guidelines, most professional and outpatient diagnostic and nondiagnostic services that are rendered within the designated timeframe of an inpatient hospital stay and are related to the inpatient hospital admission will not be reimbursed separately from the inpatient hospital stay if the services are rendered by the hospital or an entity that is wholly owned or operated by the hospital. These reimbursement guidelines do not apply in the following circumstances: The professional services are rendered in the inpatient hospital setting. The hospital and the physician office or other entity are both owned by a third party, such as a health system. The hospital is not the sole or 100-percent owner of the entity. Refer to: Section , Payment Window Reimbursement Guidelines of the Inpatient and Outpatient Hospital Services Handbook (Vol. 2, Provider Handbooks) for additional information about the payment window reimbursement guidelines. 5

6 2 Nonimplantable Hearing Aid Devices and Related Services 2.1 Enrollment To enroll in Texas Medicaid, hearing aid professionals (physicians, audiologists, and hearing aid fitters and dispensers) who provide hearing evaluations or fitting and dispensing services must be licensed by the licensing board of their profession to practice in the state where the service is performed. Hearing aid providers are eligible to enroll as individuals and facilities. Audiologists are eligible to enroll as individuals and groups. Audiologists may enroll as both audiologists and as hearing aid fitters and dispensers by completing an enrollment application for each type of provider (i.e., select Audiologist on one application and Hearing Aid on the other application). Providers cannot be enrolled if their license is due to expire within 30 days. A current license must be submitted School Districts, State Agencies, and Inpatient Facilities To be reimbursed for audiology and audiometry evaluation and diagnostic services for suspected and confirmed hearing loss (other than audiology evaluation and therapy services reimbursed to School Health and Related Services [SHARS] providers), audiologists employed by or contracted with school districts, state agencies, and inpatient hospitals must enroll as individual practitioners or group practitioners by choosing Audiologist on the enrollment application. To be reimbursed for hearing aid devices and accessories, and fitting and dispensing visits and revisits, audiologists and hearing aid fitters and dispensers employed by or contracted with school districts, state agencies, and inpatient hospitals must enroll as individual practitioners or facilities by choosing Hearing Aid on the enrollment application. Appropriately-licensed providers who want to provide both audiology services and hearing aid fitting and dispensing services must complete applications for audiologist and for hearing aid fitter and dispenser for each program for which they want to enroll. Note: A SHARS Texas Provider Identifier (TPI) cannot be used to bill for these services. 2.2 Services, Benefits, Limitations, and Prior Authorization The Texas Medicaid hearing services benefit includes those services that are medically necessary for clients of any age who have suspected or identified hearing loss that can be improved or ameliorated using a hearing aid device. Such services may be reimbursed to audiologists or hearing aid fitters and dispensers. Note: Hearing-related services that are medically necessary because of a medical condition that cannot be improved or ameliorated using a nonimplantable hearing aid device are not considered part of the Texas Medicaid hearing services benefit. Providers may refer to the other Texas Medicaid Provider Procedures Manual Handbooks for benefit and limitation information about other hearing-related services. Texas Medicaid clients of any age are eligible to receive medically necessary hearing aid devices and services through the hearing services benefit outlined in the following sections. The Texas Medicaid hearing services benefit includes a broad range of hearing services for clients of all ages and reimburses providers who are appropriately enrolled with Texas Medicaid in accordance with their licensure and scope of practice. Prior authorization is not necessary for benefits within program limitations unless specifically addressed in the sections below. 6

7 The following hearing services are benefits of Texas Medicaid to appropriately-enrolled audiologists, hearing aid fitters and dispensers, and physicians according to their licensure, scope of practice, and enrollment as indicated: Audiologists and physicians may be reimbursed for audiology and audiometry evaluation and diagnostic services for suspected and confirmed hearing loss. Hearing aid fitters and dispensers may be reimbursed for hearing aid devices and accessories and fitting and dispensing visits and revisits. Physicians may be reimbursed for physician otology and otorhinolaryngology (ENT) services. Texas Medicaid clients whose jobs are contingent on their possessing a hearing aid or who appear to have vocational potential and who need a hearing aid may be referred to the Texas Department of Assistive and Rehabilitative Services (DARS) for hearing aids Limitations and Required Forms All services provided to Texas Medicaid clients must be medically necessary. Unless otherwise specified, services may be reimbursed without prior authorization within the set limitations. In addition to services that always require prior authorization, providers may request prior authorization for medically necessary services that exceed benefit limitations. Required forms, which are indicated in the specific sections below, are not required to be submitted with the claim, but the forms must be completed and maintained in the client s medical record and made available upon request by the Texas Health and Human Services Commission (HHSC) or the Texas Medicaid & Healthcare Partnership (TMHP) for retrospective review Hearing Screenings Hearing screening provided due to client concern, or at the provider s discretion, is a benefit for clients of any age when the client is referred by a Medicaid-enrolled physician, and the screening is provided by a Medicaid-enrolled provider licensed to perform these services. Routine newborn hearing screenings and Texas Health Steps (THSteps) medical checkup hearing screenings are benefits for Texas Medicaid clients, and are included in the reimbursement for the routine service or visit Routine Hearing Screenings Routine hearing screenings that are required as part of the newborn hospital stay and as part of a THSteps medical checkup are included in the Texas Medicaid hearing services benefit. These routine screenings are not reimbursed to audiologists, hearing aid fitters and dispensers, or physicians. Newborn Hearing Screen The newborn hearing screening is included in the reimbursement to the hospital for the newborn hospital stay and is not reimbursed separately. A newborn hearing screening must be offered to each newborn by the facility where the birth occurs, through a program mandated by the Texas State Legislature and certified by the Texas Department of State Health Services (DSHS). The screening is covered as part of the newborn delivery. An infant born outside a birthing facility and not admitted to a birthing facility shall be referred to a facility that provides newborn hearing screening. If a facility is not required by legislative mandate to perform newborn hearing screening, a referral must be made to a facility that offers the screening. Refer to: Subsection 5.3.9, Newborn Examination in Children s Services Handbook (Vol. 2, Provider Handbooks) for more information about the newborn hearing screening. THSteps Medical Checkup Hearing Screen Hearing screening is a required component of the THSteps medical checkup, and a standardized audiometric hearing screening is required at specific ages according to the periodicity schedule. 7

8 Refer to: The THSteps Medical Checkups Periodicity Schedule including the footnotes, which is available on the DSHS website at for coverage criteria when performed as part of a THSteps medical checkup. Subsection , Hearing Screening in Children s Services Handbook (Vol. 2, Provider Handbooks) for more information on THSteps checkup hearing screening Additional Hearing Screenings A hearing screening requested outside of a routine newborn or THSteps medical checkup may be reimbursed as medically necessary without prior authorization using procedure code Further diagnostic testing may also be reimbursed using the appropriate procedure code as indicated in subsection 2.2.3, Audiology and Audiometry Evaluation and Diagnostic Services in this handbook Abnormal Hearing Screening Results If the screening returns abnormal results, the client must be referred to a Texas Medicaid-enrolled provider who is a licensed audiologist or physician who provides audiology services. Clients who are 20 years of age or younger and have abnormal screening results must be referred to a Texas Medicaidenrolled provider who is an audiologist or physician who is experienced with the pediatric population and who offers auditory services. The referring physician who performs the screening must complete the Physician s Examination Report, which is maintained in the client s medical record. A new Physician s Examination Report must be completed whenever there is a change in the client s hearing or a new hearing aid is needed. Retrospective review may be performed to ensure documentation supports the medical necessity of the service. In addition to being referred to an appropriate provider for further testing, clients who are 35 months of age and younger and have suspected hearing loss must be referred to Early Childhood Intervention (ECI) as soon as possible but no longer than 7 days after identification, even if the client was referred to an appropriate provider for further testing. Refer to: Subsection 2.7, Early Childhood Intervention (ECI) Services in Children s Services Handbook (Vol. 2, Providers Handbooks) for more information about ECI Audiology and Audiometry Evaluation and Diagnostic Services Audiometry is a benefit of Texas Medicaid for clients of any age. Physicians must recommend hearing evaluations based on examination of the client. Only physicians or licensed audiologists will be reimbursed for hearing evaluations. Hearing aid fitters and dispensers are not reimbursed for hearing evaluations. Important: The date of service for audiology and audiometry evaluations and diagnostic services is the date the service is rendered to the client. The date of service that is billed on the claim must match the date of service that is documented in the client s medical record. The following audiometry procedure codes are benefits of Texas Medicaid for a basic comprehensive audiometry survey: Procedure Codes The following additional procedure codes may be benefits for audiometric testing: Procedure Codes

9 Procedure Codes Refer to: The appropriate Texas Medicaid fee schedule on the TMHP web site at for procedure codes that may be reimbursed to individual types of providers. Auditory brainstem response (ABR) and otoacoustic emissions (OAE) are benefits for clients of any ages when performed to identify and diagnose hearing loss and for newborns when performed for the purpose of a newborn hearing screening. Note: ABR and OAE tests performed as part of the newborn hearing screen are reimbursed as part of the hospital visit and are not reimbursed separately Otological Examinations Otological examinations are a benefit when medically necessary and provided by a Medicaid-enrolled physician licensed to perform this service. Procedure codes and are benefits for otological examinations. An otological examination may also include physician evaluation and management (E/M) services provided to diagnose or treat medical conditions. Refer to: Subsection , Group Clinical Visits in Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook (Vol. 2, Provider Handbooks) for information about medically necessary physician E/M services Vestibular Evaluations Vestibular evaluations are a benefit when medically necessary and provided by a Medicaid-enrolled physician or nonphysician provider licensed to perform this service. The following procedure codes for vestibular evaluations are benefits: Procedure Codes Forms and Documentation Providers of hearing evaluations must have a report in the client s record. Providers must include in the report hearing evaluation test data. The Hearing Evaluation, Fitting, and Dispensing Report (Form 3503) must be completed by the physician or audiologist who conducts the diagnostic testing. The provider who signs the report must maintain it in the client s file. The report includes audiometric assessment results of the hearing evaluation and must provide objective documentation that amplification improves communication ability. Retrospective review may be performed to ensure documentation supports the medical necessity of the service. For physician diagnostic hearing services (procedure codes 92502, 92504, 92540, 95940, and 95941), providers must maintain documentation of medical necessity in the client s medical record. Retrospective review may be performed to ensure that the documentation supports medical necessity for the service Prior Authorization Hearing screening and testing services do not require prior authorization. Documentation of medical necessity must be maintained by the provider in the client s medical record. Retrospective review may be performed to ensure that the documentation supports medical necessity for the service. 9

10 Limitations Newborn hearing screenings provided during the birth admission are considered part of the newborn delivery payment to the facility and are not reimbursed as separate procedures. An otological examination is a benefit of Texas Medicaid when medically necessary and provided by a Medicaid-enrolled physician licensed to perform this service. An otological examination may also include physician E/M services provided to diagnose or treat medical conditions. Refer to: Subsection , Group Clinical Visits in Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook (Vol. 2, Provider Handbooks) for information about medically necessary physician E/M services. Audiometry survey procedure codes and evoked potential and otoacoustic emissions screening procedure codes may be reimbursed once per day. Procedure code may be reimbursed when billed with one of the following diagnosis codes: Diagnosis Codes D333 G510 G511 G518 G519 H8001 H8002 H8003 H8011 H8012 H8013 H8021 H8022 H8023 H8081 H8082 H8083 H8091 H8092 H8093 H8101 H8102 H8103 H8111 H8112 H8113 H8121 H8122 H8123 H81311 H81312 H81313 H81319 H81391 H81392 H81393 H8141 H8142 H8143 H818X1 H818X2 H818X3 H8191 H8192 H8193 H8301 H8302 H8303 H8311 H8312 H8313 H832X1 H832X2 H832X3 H838X1 H838X2 H838X3 H838X9 H8391 H8392 H8393 H900 H9011 H9012 H902 H903 H9041 H9042 H905 H906 H9071 H9072 H908 H9101 H9102 H9103 H9121 H9122 H9123 H918X1 H918X2 H918X3 H9191 H9192 H9193 H9311 H9312 H9313 H93211 H93212 H93213 H93221 H93222 H93223 H93231 H93232 H93233 H93241 H93242 H93243 H93291 H93292 H93293 H933X1 H933X2 H933X3 H933X9 Q179 R42 Providers may bill only one of the pure tone audiometry procedure codes (92551, 92252, and 92553) per day, any provider. Procedure codes and are not reimbursed on the same day by any provider. If these procedure codes are billed for the same date of service, they are denied with instructions to bill with the more appropriate, comprehensive audiometry procedure code Tympanometry Tympanometry (procedure code 92567) must be limited to selected individual cases where its use demonstrably adds to the provider s ability to establish a diagnosis and provide appropriate treatment. Tympanometry is limited to three services per rolling year when billed by any provider and is based on medical necessity, which must be documented in the client s medical record. Electrical Testing Electrical testing may be reimbursed for services rendered to clients of any age. Electrical testing (procedure code 92547) must be billed with the same date of service by the same provider as procedure code 92541, 92542, 92543, 92544, 92545, or

11 Vestibular Evaluation Vestibular evaluation is a benefit of Texas Medicaid when medically necessary and provided by a provider who is licensed to provide this service. Hearing pathway tests such as audiometry, ABR, and electrocochleography (ECoG) can also be used for the same purpose and are frequently combined with vestibular tests. ABR and OAE Hearing Screening Services Evoked response testing (procedure codes 92558, 92585, 92586, 92587, and 92588) is considered a bilateral procedure. If separate charges are billed for left- and right-sided tests of the same type, the tests are combined and reimbursed as a quantity of one. An electroencephalogram (EEG) may be reimbursed for the same date of service as evoked response testing by any provider. Procedure code may be reimbursed as often as is medically necessary. Texas Medicaid may reimburse physicians for ear and throat examination procedure codes 92502, 92504, and Audiologists will not be reimbursed for these services. Refer to: Subsection , Physician Evaluation and Management (E/M) Services in Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook (Vol. 2, Provider Handbooks) for more information about these services. Procedure codes and may be reimbursed in addition to each evoked potential test. Procedure codes and are limited to a maximum of 2 hours per day, per client, any provider, without documentation of medical necessity. Procedure codes and cannot be reported by the surgeon or anesthesiologist SHARS Audiology Services Audiology evaluation and therapy services procedure codes 92507, 92508, 92521, 92522, 92523, 92524, and may be reimbursed to school districts and state agencies that are enrolled with Texas Medicaid as SHARS providers. Refer to: Section 3, School Health and Related Services (SHARS) in Children s Services Handbook (Vol. 2, Provider Handbooks) for more information about SHARS services. Other hearing evaluation, diagnostic, and hearing aid services may be reimbursed to appropriatelyenrolled audiologists, hearing aid fitters and dispensers, and physicians as outlined in this section Noncovered Services Texas Medicaid does not reimburse for a hearing screening completed for day care, Head Start, or school unless it is part of an acute-care visit in a clinic setting. Separate procedure codes must not be billed for these services Hearing Aid Devices and Accessories (Nonimplantable) Texas Medicaid may reimburse hearing aid fitters and dispensers for the following devices and accessories: Service Hearing aid devices Limitation Limitation: For clients who are 20 years of age and younger, 1 hearing aid device per ear may be reimbursed every 5 years from the month it is dispensed. For clients who are 21 years of age and older, if the client has at least a 35 db hearing loss in both ears, 1 hearing aid device may be reimbursed every 5 years from the month it is dispensed. Either the left or the right may be reimbursed, but not both in the same 5 year period. 11

12 Service Hearing aid accessories Ear impression Ear mold Limitation Refer to: Subsection , Forms and Documentation in this handbook for additional medical necessity criteria. Replacement hearing aid devices that are required within the same 5-year period must be prior authorized. Repairs or modifications may be reimbursed without prior authorization once per year after the 1-year warranty period has lapsed if the requested repair or modification is a better alternative than a new purchase. Procedure codes: See below for monaural and binaural procedure codes. Procedure code V5014 may be reimbursed for repairs and modifications. Date of service: The date of service for the initial hearing aid device is the date the client successfully completes the 30-day trial period and accepts the hearing aid device. Note: During the warranty period, Texas Medicaid may reimburse providers for a replacement hearing aid and replacement hearing aid batteries. Texas Medicaid will not reimburse hearing aid repairs or modifications that are rendered during the 12-month manufacturer s warranty period. Providers must follow the manufacturer s repair process as outlined in their warranty contract. Limitation: As often as is medically necessary for clients who are 20 years of age and younger with prior authorization. Note: Hearing aid accessories include, but are not limited to, chin straps, clips, boots, and headbands. Procedure code: V5267 Date of service: The date of service is the date the client successfully completes the 30-day trial period and accepts the hearing aid device or the date the client receives the replacement accessory item. Limitation: 1 each per hearing aid device as follows: For one impression, bill a quantity of 1. For two impressions, bill a quantity of 2. Procedure codes: V5275 Date of service: The date of service for the ear impression is the date the ear impression is taken. Limitation: As medically necessary for clients who are 20 years of age and younger. For clients who are 21 years of age and older: 3 ear molds per rolling year for custom ear molds 4 ear molds per rolling month for disposable ear molds Ear molds must be billed using the appropriate LT or RT modifier. Replacement ear molds may be reimbursed as often as is medically necessary without prior authorization. Documentation of medical necessity must be maintained in the client s medical record. Procedure codes: V5264 and V5265 Date of service: The date of service for the ear mold is the date the ear mold is taken. 12

13 Service Batteries (Replacement only) Limitation Limitation: Replacement batteries may be reimbursed as often as is medically necessary when a hearing aid device has been previously reimbursed by Texas Medicaid. Note: If a hearing aid has not been reimbursed by Texas Medicaid in the last 5 years, the replacement batteries may be reimbursed on appeal with a statement that documents medical necessity. Procedure code: V5266 Date of service: The date of service is the date the client receives the replacement batteries. The following monaural procedure codes may be reimbursed for medically necessary hearing aid devices and replacements that are rendered to clients of any age when they are billed with the appropriate modifier LT or RT to indicate for which ear the hearing aid device was purchased and fitted: Procedure Codes V5030 V5040 V5244 V5245 V5246 V5247 V5254 V5255 V5256 V5257 V5298 Procedure codes V5170 and V5180 may be reimbursed for monaural hearing aids that are rendered to clients who are 20 years of age and younger only. The following binaural procedure codes may be reimbursed for medically necessary hearing aid devices and replacements that are rendered to clients who are 20 years of age and younger: Procedure Codes V5100 V5210 V5220 V5249 V5250 V5251 V5252 V5253 V5258 V5259 V5260 V5261 V5298 Binaural hearing aid procedure codes must be submitted with a quantity of 1 per procedure code. Providers can refer to the Online Fee Lookup (OFL) or the applicable fee schedule on the TMHP website at for reimbursement rates. Refer to: Section 2.4.2, Reimbursement in this handbook for more information about manual pricing Forms and Documentation Monaural hearing aids may be reimbursed for clients who have no medical contraindication for using a hearing aid and who have documentation of medical necessity. The following documentation of medical necessity must be maintained in the client s medical record: Hearing loss in the better ear of 35 db or greater for the pure tone average of 500, 1000, 1500, and 2000 Hz, or a spondee threshold in the better ear of 35 db or greater when pure tone thresholds cannot be established Documentation of communication need and a statement that the patient is alert and oriented and able to use the device appropriately by themselves or with assistance Clients who are 21 years of age and older must meet the medical necessity criteria outlined above and have at least a 35 db hearing loss in both ears to qualify for the purchase of a monaural hearing aid device. Clients who are 20 years of age and younger must meet the medical necessity criteria outlined above and have at least a 35 db hearing loss in both ears to qualify for the purchase of binaural hearing aid devices. 13

14 Claims for non-implantable hearing aid devices must be submitted with a manufacturer invoice showing the net acquisition cost of the non-implantable hearing aid device. An invoice printed from an or the Internet will not be accepted and should not be submitted with the claim as documentation to show the net acquisition cost of the hearing aid device unless the invoice reflects the actual price the provider paid for the hearing aid device. Note: The requirement to submit the net acquisition cost of the hearing aid device applies only to non-implantable monaural and binaural hearing aid devices including, but not limited to, procedure code V5298. Refer to: Subsection , Place of Service (POS) Coding in Section 6, Claims Filing (Vol. 1, General Information) for more information about coding place of service for other locations Prior Authorization Prior authorization is not required for medically necessary hearing aid devices and supplies that are provided within the limitations outlined in the table above. Prior authorization is required for the following: Replacement hearing aid devices that are required within the same 5-year period. A replacement hearing aid device may be considered for prior authorization when loss or irreparable damage has occurred. A copy of the police or fire report, when appropriate, and measures to be taken to prevent reoccurrence must be submitted with the prior authorization request. Replacements will not be authorized when the equipment has been abused or neglected by the client, the client s family, or the caregiver. Hearing aid accessories for clients who are birth through 20 years of age. Requests for prior authorization for children s hearing aid accessories including, but not limited to, chin straps, clips, boots, and headbands will be considered when the requests are submitted with documentation that shows that the client is birth through 20 years of age and that the requested supply is medically necessary for the proper use or functioning of the hearing aid device. Hearing aid devices that are not currently a benefit of Texas Medicaid but that are medically necessary for clients who are birth through 20 years of age (using procedure code V5298). The prior authorization request must include: The medical necessity for the requested hearing aid device. The name of the manufacturer. The model number, serial number, and the dates that the warranty is in effect for the requested hearing aid. Additional medically necessary repairs or modifications beyond 1 per year. For additional repairs or modifications, requests for prior authorization must include documentation that supports the need for the requested repair. For services that require prior authorization, prior authorization must be obtained before the services are rendered. The prior authorization number must be included on the claim form when the claim is submitted to TMHP. 14

15 Prior authorization requests must be submitted to the TMHP Special Medical Prior Authorization (SMPA) Department with documentation that supports medical necessity for the requested device, service, or supply. Authorization may be submitted on the TMHP website at or by fax to Important: For clients who are birth through 20 years of age, if the authorization request is denied because it does not meet benefit criteria, the TMHP SMPA Department will refer the request to the TMHP Comprehensive Care Program (CCP) Department for consideration under CCP. The provider is not required to complete additional forms or request referral to the TMHP CCP Department. Providers may use the form of their choice to submit the required information to the TMHP SMPA Department. No specific request form is required. Refer to: Section 6: Claims Filing (Vol 1, General Information) for more information about the authorizations and claims filing processes Limitations The following services and supplies must be provided to Texas Medicaid clients if a nonimplantable hearing aid device is medically necessary: An individual client assessment to identify the appropriate type of device The fitting/implantation of the device The re-assessment to determine whether the device allows for adequate hearing Expendable supplies that are necessary to keep the device functioning properly, such as batteries and accessories A hearing aid dispensed through Texas Medicaid must meet the following criteria: Be a new and current model Meet the performance specifications indicated by the manufacturer Include, at minimum, a standard 12-month warranty that begins on the dispensing date of the hearing aid. Providers must dispense each hearing aid reimbursed through Texas Medicaid with all necessary hearing aid accessories and supplies, including a 1-month supply of batteries. The reimbursement for monaural and binaural procedure codes includes the required hearing aid package as follows, and no separate reimbursement will be made for these items: Acquisition cost of the hearing aid (the actual cost or net cost of the hearing aid after any discounts have been deducted) Manufacturer s postage and handling charges All necessary hearing aid accessories or supplies Instructions for care and use A 1-month supply of batteries Note: TMHP does not supply the hearing aid devices, supplies, and accessories. Providers must purchase equipment directly from manufacturers and vendors of their choice and submit claims to TMHP for reimbursement using the appropriate procedure codes. Procedure code V5298 may be reimbursed with prior authorization for hearing aid devices that are not currently a benefit of Texas Medicaid but that are medically necessary for clients who are birth through 20 years of age. 15

16 Services for residents in a skilled nursing facility (SNF), intermediate care facility (ICF), or extended care facility (ECF) must be ordered by the attending physician. The order must be on the client s chart, must state the condition that necessitates the hearing aid services, and must be signed by the attending physician Hearing Aid Services The following additional hearing aid related procedures are benefits for services that are rendered to clients of any age: Procedure Codes V5010 V5011 V5264 V5265 V5275 The following additional hearing aid related procedures are benefits for services that are rendered to clients who are 20 years of age and younger only: Procedure Codes Texas Medicaid may reimburse hearing aid fitters and dispensers for the following services: Service Hearing test for sensitivity Fitting and dispensing visits Revisit(s) Limitation Limitation: As often as is medically necessary Procedure code: (SISI hearing test) Limitation: 1 fitting per hearing aid procedure code per 5 rolling year period, regardless of the number of times a device is returned as unacceptable during a 30-day trial period Procedure code: V5011 Limitation: 1 dispensing fee each time a hearing aid is dispensed and a new 30-day trial period begins Procedure codes: V5090 and V5241 (for clients of any age) and V5110, V5160, V5200, and V5240 (for clients who are 20 years of age and younger) The dispensing fee may be reimbursed separately from the fitting of the hearing aid. The post-fitting check is included in the reimbursement for the dispensing procedure and is not reimbursed separately. Limitation: 2 per calendar year when billed by any provider Procedure codes: (first and second revisits for monaural fittings for clients of any age) and (first and second revisits for binaural fittings for clients who are 20 years of age and younger) Note: Services for Texas Medicaid clients who are 21 years of age and older and who received 2 hearing aid devices (binaural) on or before October 1, 2012, may be reimbursed to the client s treating physician or audiologist using procedure codes and Hearing aid revisits are limited to a total of two per calendar year by any provider. 16

17 Forms and Documentation The forms and documentation required for the fitting and dispensing visits are as follows: Physician Examination Report Hearing Evaluation, Fitting, and Dispensing Report (Form 3503) Client acknowledgement statement (created by the provider) 30-day trial period certification statement (created by the provider) Additional necessary documentation Physician s Examination Report The referring physician who performs the screening must complete the Physician s Examination Report, which is maintained in the client s medical record. Hearing Evaluation, Fitting, and Dispensing Report (Form 3503) The Hearing Evaluation, Fitting, and Dispensing Report (Form 3503) must be completed by the fitter/dispenser that conducts the fitting and dispensing visit. The provider who signs the report must maintain it in the client s file. The report includes audiometric assessment results of the hearing evaluation and must provide objective documentation to support improved communication ability with amplification. Retrospective review may be performed to ensure documentation supports the medical necessity of the device, service, or supply. Client Acknowledgement Statement (created by the provider) At the time the hearing aid device and supplies are dispensed, the client must sign a client acknowledgement statement to verify the client was evaluated and offered an appropriate hearing aid that meets the client s hearing need. The acknowledgement statement must include language that indicates the client is responsible for paying any hearing aid rental fees if charged. The provider must obtain the signed acknowledgment statement before dispensing the hearing aid device and supplies and must keep the signed acknowledgment statement in the client s file. Retrospective review may be performed to ensure documentation supports the medical necessity of the device, service, or supply. 30-Day Trial Period Certification Statement (created by the provider) Fitters and Dispensers must inform clients in writing of the trial period lasting 30 consecutive days. The statement, which must be created by the provider and signed by the client, must contain the start and end dates of the trial period, all charges and fees associated with the trial period, an acknowledgment that the client accepts responsibility for any assessed rental fees, and the name, address, and telephone number of the State Board of Examiners for Speech-Language Pathology and Audiology. The client must receive a copy of this agreement. After at least 30 days and the successful completion of the trial period, the provider must update the statement to indicate that the trial was successful and the client accepted the dispensed hearing aid device. The updated statement must be maintained in the client s file. Retrospective review may be performed to ensure documentation supports the medical necessity of the device, service, or supply. For hearing aids that are dispensed in a provider s office, if a client fails to return by the end date of the trial period, the provider must contact the client. After 3 attempts have been made, if the client does not return to the provider s office, the provider must document all attempts to contact the client and must maintain this documentation in the client s file. Retrospective review may be performed to ensure documentation supports the contact attempts and the client s failure to return to the provider s office. This requirement does not apply for services that are rendered to clients who receive hearing aids in other places of service (i.e., nursing homes) Prior Authorization Prior authorization is not required for fitting and dispensing visits and revisits. 17

18 Limitations The following hearing aid visits may be reimbursed by Texas Medicaid: The fitting and dispensing visits that encompass a 30-day trial period and include a post-fitting check 5 weeks after the trial period has been successfully completed A first revisit as needed after the post-fitting check A second revisit as needed after the first revisit The fitting visit includes the fitting, dispensing, and post-fitting check of the hearing aid. Providers must allow each Texas Medicaid client a 30-consecutive-day trial period that begins with the dispensing date. This trial period gives the client time to determine whether the hearing aid device meets the client s needs. If the client is not satisfied with the purchased hearing aid, the client may return it to the provider, who must accept it. If the device is returned within 30 days of the date it was dispensed, the provider may charge the client a rental fee not to exceed $2 per day. This fee is not a benefit of Texas Medicaid and will not be reimbursed. The client is responsible for paying the hearing aid rental fees if the provider chooses to charge a fee for the rental of returned hearing aid devices. During the trial period, providers may dispense additional hearing aids as medically necessary until either the client is satisfied with the results of the hearing aid or the provider determines that the client cannot benefit from the dispensing of another hearing aid. The dispensing date of each additional hearing aid starts a new trial period. The licensed audiologist or fitter/dispenser must perform a post-fitting check of the hearing aid within 5 weeks of the initial fitting. The first and second revisits are available if additional visits are required after the post-fitting check. First revisit. The first revisit must include a hearing aid check. Second revisit. The second revisit is available as needed after the post-fitting check and first revisit. The second revisit must include either a real ear measurement or aided sound field testing according to the guidelines specified for the hearing evaluation. If the aided sound field test scores suggest a decrease in hearing acuity, the provider must include puretone and speech audiometry readings from the first evaluation. Home visit hearing evaluations and fittings are permitted only with the physician s written recommendation. Services for residents in an SNF, ICF, or ECF must be ordered by the attending physician. The order must be on the client s chart, must state the condition that necessitates the hearing aid services, and must be signed by the attending physician. 2.3 Documentation Requirements All services, including hearing services, require documentation to support the medical necessity of the service rendered. Hearing services are subject to retrospective review and recoupment if documentation does not support the service billed. Required forms for nonimplantable hearing devices and services, which are indicated in the specific sections above, are not submitted with the claim to TMHP, but the forms must be completed and maintained in the client s medical record and made available upon request by HHSC or TMHP for retrospective review. 18

19 2.4 Claims Filing and Reimbursement Claims Filing Hearing services must be submitted to TMHP in an approved electronic format or on the CMS-1500 paper claim form. Providers may purchase CMS-1500 paper claim forms from the vendor of their choice. TMHP does not supply the forms. When completing a CMS-1500 paper 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. Refer to: Subsection 2.2, Fee-for-Service Reimbursement Methodology in Section 2, Texas Medicaid Fee-for-Service Reimbursement (Vol. 1, General Information) for more information about reimbursement. Subsection 1.6.9, Billing Clients in Section 1, Provider Enrollment and Responsibilities (Vol. 1, General Information). Section 3: TMHP Electronic Data Interchange (EDI) (Vol. 1, General Information) for information on electronic claims submissions. Subsection 6.1, Claims Information in Section 6, Claims Filing (Vol. 1, General Information) for general information about claims filing. Subsection 6.5, CMS-1500 Paper Claim Filing Instructions in Section 6, Claims Filing (Vol. 1, General Information). Blocks that are not referenced are not required for processing by TMHP and may be left blank. Providers must file all claims electronically or on the appropriate Centers for Medicare & Medicaid Services (CMS) paper claim form after providing the services. Exception: Claims for non-implantable hearing aid devices must be submitted on the CMS-1500 paper claim form because electronic claim submissions do not allow for the submission of attachments. Claims must include the following information: The most appropriate International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis code that represents the purpose for the service. The most appropriate Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) procedure code(s) that represent the service(s) provided. The appropriate information as indicated on the provider enrollment letter (Electronic claims must also include the most appropriate attested taxonomy code.) Note: For Texas Medicaid managed care clients, all hearing aid benefits and otology, and audiometry services are administered by the client s Medicaid managed care organization (MCO) Non-implantable Hearing Aid Devices To be reimbursed for a non-implantable hearing aid device, providers must submit documentation with the paper claim showing their cost for the hearing aid device. The Texas Health and Human Services Commission (HHSC) requires providers to submit non-implantable hearing aid claims using the CMS paper claim form because electronic claim submissions do not allow for the submission of attachments. 19

20 Providers must use the net acquisition cost as the amount billed on the claim. The net acquisition cost is the actual price the provider paid for the device, including the wholesale cost plus sales tax, shipping and handling, and any reductions resulting from discounts or rebates. Providers must not use usual and customary fees as the amount billed. The documentation submitted with the claim must be a manufacturer invoice showing the net acquisition cost of the non-implantable hearing aid device. An invoice printed from an or the Internet will not be accepted and should not be submitted with the claim as documentation to show the net acquisition cost of the hearing aid device unless the invoice reflects the actual price the provider paid for the hearing aid device Third Party Liability Standard third party liability (TPL) rules apply to all hearing services claims. Refer to: Subsection 4.12, Third Party Liability (TPL) in Section 4, Client Eligibility (Vol. 1, General Information) Reimbursement Hearing aid devices and all hearing and audiological services are reimbursed in accordance with 1 TAC To be reimbursed for both audiology services and hearing aid fitting and dispensing services, audiologists must enroll with Texas Medicaid as audiologists and also as hearing aid fitters and dispensers. Audiology services must be billed using the audiologist provider number and benefit code (for electronic claims only) as indicated on the provider enrollment letter that indicates Audiologist, and hearing aid and fitting and dispensing services must be billed with the hearing aid provider number and benefit code (for electronic claims only) as indicated on the provider enrollment letter that indicates Hearing Aid. Requested items that are not represented by a specific procedure code must be prior authorized and are priced manually during the authorization process. Manually priced items for clients who are birth through 20 years of age require prior authorization that must be obtained through the TMHP SMPA Department. The reimbursement will be determined based on either the MSRP less 18 percent or based on the provider s documented invoice cost if there is no MSRP available. Manually priced items are indicated with Note Code 5 in the Texas Medicaid fee schedule. Texas Medicaid implemented mandated rate reductions for certain services. The OFL and static fee schedules include a column titled Adjusted Fee to display the individual fees with all mandated percentage reductions applied. Additional information about rate changes is available on the TMHP website at Providers may refer to the OFL or the applicable fee schedule on the TMHP website at National Correct Coding Initiative (NCCI) and Medically Unlikely Edit (MUE) Guidelines The HCPCS and CPT codes included in the Texas Medicaid Provider Procedures Manual are subject to NCCI relationships, which supersede any exceptions to NCCI code relationships that may be noted in the manuals. Providers should refer to the CMS NCCI web page for correct coding guidelines and specific applicable code combinations. In instances when Texas Medicaid limitations are more restrictive than NCCI MUE guidance, Texas Medicaid limitations prevail. 20

21 3 Implantable Hearing Devices and Related Services 3.1 Enrollment To enroll in Texas Medicaid, hearing services professionals who provide implantable hearing devices and services must be appropriately enrolled according to their licensure and scope of practice. Providers cannot be enrolled if their license is due to expire within 30 days. A current license must be submitted. 3.2 Services, Benefits, Limitations and Prior Authorization Implantable hearing devices, including the cochlear implant device, the auditory brainstem implant (ABI), and the bone anchored hearing aid (BAHA), are benefits of Texas Medicaid for clients of all ages. The following services and supplies must be provided to Texas Medicaid clients if an implantable hearing aid device is medically necessary: An individual client assessment to identify the appropriate type of device The fitting of the device The reassessment to determine whether the device allows for adequate hearing Expendable supplies that are necessary to keep the device functioning properly, such as batteries and accessories Cochlear Implants The following procedure codes may be reimbursed for the cochlear implant device, separate components, and services: Procedure Codes L7368 L8499 L8614 L8615 L8616 L8617 L8618 L8619 L8621 L8622 L8623 L8624 L8627 L8628 L8629 The following procedure codes may be reimbursed for diagnostic analysis of the cochlear implant: Procedure Codes Prior Authorization Prior authorization is required for the following: Cochlear implant surgery, device, and replacement parts Sound processor repair or replacement Battery recharger unit Replacement batteries beyond the limitations outlined in the sections below Requests for prior authorization must be submitted by the provider to the SMPA Department with documentation supporting the medical necessity for the requested device, service, or supply. Note: Requests for clients who are 20 years of age or younger who do not meet the medical necessity criteria may be considered through Comprehensive Care Program (CCP). Documentation submitted for review must indicate who will be providing the cochlear implant device (i.e., the facility or the Durable Medical Equipment (DME) or medical supplier). The supplier s provider number must be included on the prior authorization request. 21

22 Prior authorization for a unilateral or bilateral cochlear implant may be granted for clients who are 12 months of age and older with documentation of all of the following criteria: Cognitive ability to use auditory cues and written documentation of agreement by the client or the client s parent or guardian that the client will participate in a program of post-implantation auditory rehabilitation. This documentation must be maintained in the client s medical record. Postlingual deafness or prelingual deafness. Freedom from middle-ear infection, an accessible cochlear lumen that is structurally suited to implantation, and freedom from lesions in the auditory nerve and acoustic areas of the central nervous system. No contraindications to surgery. Inability to derive benefit from appropriately fitted hearing aid devices. Documentation of poor speech discrimination and a recommendation for cochlear implant candidacy and the most appropriate ICD-10-CM diagnoses for severe-to-profound bilateral sensorineural hearing loss. The initial lithium ion battery recharger unit, additional medically necessary units, and additional replacement batteries beyond the limitations indicated in the following sections may be reimbursed with prior authorization. Documentation must be submitted with the prior authorization request to support medical necessity for the request. Refer to: Subsection 3.2.4, Sound Processor Replacement and Repair in this handbook for more information about sound processor repair or replacement Limitations Surgery Procedure code with the appropriate modifier LT or RT may be reimbursed for unilateral cochlear implantation. Procedure code with modifier 50 may be reimbursed for bilateral cochlear implantation performed simultaneously. Device and Components Procedure codes L8627, L8628, and L8629 for the cochlear implant device and components may be reimbursed for clients who are 12 months of age and older as follows: The device must be approved by the Food and Drug Administration (FDA) and be age-appropriate for the client. One per day may be reimbursed with prior authorization. The cochlear implant device and the surgery to implant the device may be reimbursed separately. Replacement Batteries and Related Items Replacement batteries and related items for the cochlear implant device include non-rechargeable batteries, rechargeable batteries, and recharger units as follows: Procedure Code Prior Authorization Limitation L8621 (Zink air non-rechargeable) Not required Maximum of 50 per month L8622 (Alkaline non-rechargeable) Not required Maximum of 31 per month L8623 (Lithium ion rechargeable) Not required 2 batteries per calendar year L8624 (Lithium ion rechargeable) Not required 2 batteries per calendar year L7368 (Battery recharger unit for lithium ion rechargeable batteries) Required 1 replacement unit every 5 rolling years 22

23 Replacement batteries for clients with bilateral cochlear implants and two sound processors may be reimbursed when billed with the applicable battery procedure code and the appropriate LT or RT modifier. Replacement batteries for the cochlear device are limited to clients with a previously paid cochlear implant procedure, device, or supply. Replacement batteries for clients who did not receive the cochlear implant through Texas Medicaid will be considered for reimbursement on appeal with a physician s statement documenting medical necessity. Additional batteries and lithium ion battery recharger units beyond these limitations may be reimbursed with prior authorization Auditory Rehabilitation Auditory rehabilitation is a benefit of Texas Medicaid when it is medically necessary for clients who have received a surgically implanted hearing device, or who have prelingual or postlingual hearing loss when the treating physician has determined that auditory rehabilitation would be beneficial. The following procedure codes may be reimbursed for auditory rehabilitation: Procedure Codes L One auditory rehabilitation evaluation and 12 visits per six rolling months may be reimbursed without prior authorization. Additional visits during a six rolling month period for clients who are 12 months of age through 20 years of age require prior authorization. Procedure code is an add-on procedure, and must be billed with the primary procedure code to be considered for reimbursement. Note: Additional therapy services may be a benefit through the Texas Medicaid speech therapy benefit. Refer to: Subsection 2.5.5, Speech Therapy (ST) in the Children s Services Handbook (Vol. 2, Provider Handbooks) and subsection 4.2.3, ST Services in the Nursing and Therapy Services Handbook (Vol. 2, Provider Handbooks) for information about the speech therapy benefit. Frequency modulated (FM) systems are not benefits of Texas Medicaid Auditory Brainstem Implant (ABI) The following procedure codes may be reimbursed for the ABI, related components, and services: Procedure Codes L92640 L8499 L8614 L8621 L8622 S Prior Authorization The following implantable hearing devices and services require prior authorization: ABI surgery, device, and replacement parts Sound processor repair or replacement Replacement batteries beyond the limitations outlined in the sections below Requests for prior authorization must be submitted to the SMPA Department with documentation supporting the medical necessity for the requested device, service, or supply. Prior authorization requests and claims for ABI is limited to clients with a condition of neurofibromatosis, type II or schwannomatosis. 23

24 Refer to: Subsection 2.2.1, Limitations and Required Forms in this handbook for additional information about replacement batteries. Subsection 3.2.4, Sound Processor Replacement and Repair in this handbook for more information about sound processor repair or replacement Limitations ABI is a benefit for clients who are 12 years of age and older. Diagnostic analysis of the ABI (procedure code 92640) is limited to 2 hours per day when billed by any provider Bone-Anchored Hearing Aid (BAHA) The following procedure codes must be submitted for the BAHA and related components: Procedure Codes L8690 L8691 L8692 L8693 V Prior Authorization The following implantable hearing devices and services require prior authorization: BAHA implant surgery, device, and replacement parts Sound processor repair or replacement Requests for prior authorization must be submitted to the SMPA Department with documentation supporting the medical necessity for the requested device, service, or supply. Prior authorization requests may be granted for clients who are 5 years of age and older with all of the following: Documentation of previous attempts at hearing aid devices and why these devices are inadequate or have failed Documentation of scores on hearing tests for bone conduction thresholds and on maximum speech discrimination Documentation of audiological testing showing good inner ear function Documentation of a multidisciplinary assessment including physical, cognitive, communicative, and behavioral limitations describing the client s auditory disability and expected benefit with use of the BAHA implant Documentation of an appropriate diagnosis. Benefit-eligible conditions may include, but are not limited to the following: Conductive hearing loss Sensorineural hearing loss Other anomalies of external ear with impairment of hearing Anomalies of skull and face bones Refer to: Subsection 3.2.4, Sound Processor Replacement and Repair in this handbook for more information about sound processor repair or replacement Limitations BAHAs are a benefit for clients who are 5 years of age and older. 24

25 Replacement batteries for the BAHA (procedure code V5266) do not require prior authorization. The replacement batteries are limited to clients with a previously paid hearing device. Replacement batteries for clients who did not receive the hearing device through Texas Medicaid will be considered for reimbursement on appeal with a physician s statement documenting the medical necessity. Procedure codes L8691, L8692, and L8693 will be denied as part of another service when billed by any provider with the same date of service as procedure code L8690. Procedure code L8692 for the BAHA device and components may be reimbursed once per day with prior authorization. Bilateral BAHA procedures are not benefits of Texas Medicaid Sound Processor Replacement and Repair Prior Authorization Replacement and repair of a sound processor require prior authorization. Documentation by the provider must explain the need for the replacement of the sound processor. The processor must be used for a minimum of 12 months before replacement of the unit will be considered. The prior authorization request must include evidence of the purchase, such as the manufacturer s warranty. Repair of a sound processor will be considered for prior authorization with documentation of medical necessity for the requested repair. Repair of a sound processor will be manually priced at the time the prior authorization is reviewed and granted. If the actual cost of the repair differs from the prior authorized fee, the provider must contact the SMPA Department to update the authorization before filing a claim for the repair services Limitations Procedure code L8499 with modifier RB may be reimbursed for sound processor repair. Repair or replacement of a sound processor is not a benefit during the manufacturer s warranty period Electromagnetic Bone Conduction Hearing Device - Removal Only The removal of the electromagnetic bone conduction hearing aid may be reimbursed by Texas Medicaid using procedure code The removal or repair of an electromagnetic bone conduction hearing device is limited to two procedures per lifetime when billed by any provider. The implantation of the device is not a benefit of Texas Medicaid. 3.3 Documentation Requirements All implantable hearing aid services require documentation to support the medical necessity of the service rendered. Hearing services are subject to retrospective review and recoupment if documentation does not support the service billed. 3.4 Claims Filing and Reimbursement Claims Filing Hearing services must be submitted to TMHP in an approved electronic format or on the CMS-1500 paper claim form. Providers may purchase CMS-1500 paper claim forms from the vendor of their choice. TMHP does not supply the forms. 25

26 When completing a CMS-1500 paper 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. Refer to: Note: Subsection 2.2, Fee-for-Service Reimbursement Methodology in Section 2, Texas Medicaid Fee-for-Service Reimbursement (Vol. 1, General Information) for more information about reimbursement. Subsection 1.6.9, Billing Clients in Section 1, Provider Enrollment and Responsibilities (Vol. 1, General Information). Section 3: TMHP Electronic Data Interchange (EDI) (Vol. 1, General Information) for information on electronic claims submissions. Subsection 6.1, Claims Information in Section 6, Claims Filing (Vol. 1, General Information) for general information about claims filing. Subsection 6.5, CMS-1500 Paper Claim Filing Instructions in Section 6, Claims Filing (Vol. 1, General Information). Blocks that are not referenced are not required for processing by TMHP and may be left blank. For Texas Medicaid managed care clients, all implantable hearing devices and services are administered by the client s Medicaid MCO Third Party Liability Standard TPL rules apply to all hearing services claims. Refer to: Subsection 4.12, Third Party Liability (TPL) in Section 4, Client Eligibility (Vol. 1, General Information) Reimbursement Implantable hearing aids and related services are reimbursed in accordance with 1 TAC Implantable hearing aids and related services are reimbursed at the lesser of the billed charges or the published Texas Medicaid fee. Unless otherwise indicated, providers may not make additional charges to the client for covered services; such charges constitute a breach of the Texas Medicaid contract. Requested items that are not represented by a specific procedure code must be prior authorized and are priced manually during the authorization process. Manually priced items for clients who are birth through 20 years of age require prior authorization that must be obtained through the TMHP SMPA Department. The reimbursement will be determined based on either the MSRP less 18 percent or based on the provider s documented invoice cost. Manually priced items are indicated with MP in the reimbursement rate table at the end of this article. Texas Medicaid implemented mandated rate reductions for certain services. The OFL and static fee schedules include a column titled Adjusted Fee to display the individual fees with all mandated percentage reductions applied. Additional information about rate changes is available on the TMHP website at Providers may refer to the OFL or the applicable fee schedule on the TMHP website at NCCI and MUE Guidelines The HCPCS and CPT codes included in the Texas Medicaid Provider Procedures Manual are subject to NCCI relationships, which supersede any exceptions to NCCI code relationships that may be noted in the manuals. Providers should refer to the CMS NCCI web page for correct coding guidelines and specific applicable code combinations. In instances when Texas Medicaid limitations are more restrictive than NCCI MUE guidance, Texas Medicaid limitations prevail. 26

27 4 Vision Care Professionals 4.1 Enrollment To enroll in Texas Medicaid, optometrists (doctors of optometry [ODs]) and ophthalmologists 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 or ophthalmologist cannot be enrolled if their license is due to expire within 30 days; a current license must be submitted. 4.2 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 Your Texas Benefits Medicaid card. Refer to the Your Texas Benefits Medicaid card website at to determine whether eyeglasses have been reimbursed by Texas 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 Your Texas Benefits Medicaid card website because of the delay in updating form information. Submit claims for eyewear services as soon as possible so the client s record indicates that eyewear or eyeglasses have been dispensed. Have the client, parent, or guardian sign and date the Vision Care Eyeglass Patient (Medicaid Client) Certification Form and retain it in their records. When a client chooses an eyeglass or contact lens option beyond the program limitations, or if nonprosthetic eyeglasses or contact lenses are replaced because of loss or destruction, the client must acknowledge their choice and his/her liability for the cost difference by signing the Vision Care Eyeglass Patient (Medicaid Client) Certification Form. The form must remain in the provider s records. Do not charge a Medicaid client more than a patient not enrolled in Texas 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. 4.3 Services, Benefits, Limitations, and Prior Authorization Examination and treatment of eye conditions, including prescribing and dispensing of medically necessary eyeglasses or contact lenses, are benefits of Texas Medicaid and may be reimbursed to optometrist, ophthalmologist, and optician providers as is within the scope of practice for each. The following services are included in other services and will not be considered for separate reimbursement: Vision screening conducted to meet State screening requirements, such as the DSHS School Vision and Hearing Screening Program. 27

28 Expenses for medical supplies, equipment, and other items that are not specifically made-to-order for the client are considered to have been incurred on the date the item is delivered. Ophthalmologist and Optometrist Examination and treatment services rendered by an ophthalmologist or optometrist are not limited to the procedure codes included in this handbook. Refer to: The Texas Medicaid fee schedules on the TMHP web site at for a complete list of procedure codes that may be reimbursed by Texas Medicaid. Optician Services rendered by an optician are limited to fitting and dispensing of medically necessary eyeglasses and contact lenses. Note: In accordance with the Omnibus Reconciliation Act of 1986, Section 9336, a Doctor of Optometry is considered a physician, with respect to the provision of any item or service the optometrist is authorized to perform by state law or regulation Services Performed in Long-Term Care Facilities Ophthalmological, optometric, and eyeglass or contact lens services provided in a skilled or intermediate care facility may be reimbursed when the client s attending physician has ordered the service and the signed order is included in the client s medical record at the nursing facility. The ordering physician s name and provider identifier must be documented on the claim when ophthalmological, optometric, or eyeglasses or contact lenses services are performed in a skilled or intermediate care facility Services Performed in Federally Qualified Healthcare Centers (FQHC) Vision services rendered by FQHC providers may be reimbursed based on an all-inclusive rate per visit. Refer to: Subsection 2.2, Services, Benefits, Limitations, and Prior Authorization in Clinics and Other Outpatient Facility Services Handbook (Vol. 2, Provider Handbooks) for information about vision services that may be reimbursed to FQHC providers THSteps Medical Checkup Vision Screening A vision screening must be completed during each THSteps medical checkup with standardized screenings performed at specific ages, as listed in the THSteps Periodicity Schedule. Providers may perform a vision screening during an acute care visit with the appropriate screening tools or refer at-risk infants and children to an optometrist or ophthalmologist who is experienced with the pediatric population and who can perform further testing, diagnosis, and treatment. Refer to: Subsection , Vision Screening in Children s Services Handbook (Vol. 2, Provider Handbooks) for information about THSteps medical checkup vision screenings Vision Screening Outside of a THSteps Preventive Care Medical Checkup Vision screening for clients who are birth through 20 years of age may be completed at any office visit upon the following: Request from a parent Referral from a school vision screening program Referral from a school nurse Clients who are birth through 20 years of age must be screened for eye abnormalities by history, observation, and physical exam. Clients who are identified as high risk must be referred to an appropriate Medicaid-enrolled provider that is experienced with the pediatric population. 28

29 4.3.4 Noncovered Services The following services and supplies are not a benefit of Texas Medicaid: Artificial eyes for clients who are 21 years of age and older. Eyeglasses for residents of institutions where the reimbursement formula and vendor reimbursement include this service. Eyeglasses or contact lenses prescribed or dispensed to clients at a hospital or nursing facility without documented orders of the attending physician in the client s medical records. Low vision aids. Optional eyeglass features that are requested by the client but that do not increase visual acuity (e.g., lens tint, industrial hardening, and decorative accessories or lettering). Plano sunglasses. Prisms that are ground into the lenses. Extended color vision examination (procedure code 92283), dark adaptation examination (procedure code 92284), and vision screening (procedure code or 99173). Spectacle (eyeglass) fitting services. Clients may be billed for noncovered frames and other items beyond Medicaid benefits. 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: Texas Medicaid may reimburse providers a total of $27.93 for eyeglass frames that are within the provider s selection for Medicaid reimbursement plus the allowed cost per lens. If the client chooses a pair of frames (such as $200 frames) that are outside of the provider s selections for Medicaid reimbursement and if the client chooses other items or services that are not a benefit of Texas Medicaid (such as tinted lenses for an extra $10 charge), the client is responsible for and may be billed for the balance of the cost of the frames ($172.07) and the other items that are not a benefit of Medicaid ($10 for 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, scratch-resistant coating), 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. Note: A client who requires low vision aids or who experiences vision-related difficulty with daily living activities or with employment may be referred to the DARS Division for Blind Services for evaluation and any appropriate resources. 29

30 4.3.5 Vision Testing Vision testing and examination and treatment of eye conditions are benefits of Texas Medicaid and may be reimbursed to ophthalmologist or optometrist providers. Eye examinations with refraction testing may be reimbursed using the following procedure codes: Procedure Codes S0620 S0621 Medical evaluation and examination may be reimbursed using the following procedure codes: Procedure Codes Refer to: Subsection , New and Established Patient Services in Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook (Vol. 2, Provider Handbooks) for information about new patient and established patient E/M services. Vision testing procedure codes are subject to the CMS NCCI relationships. Claims that are submitted by physicians with the same specialty who are in the same group practice are processed as if they were the same provider. Providers should refer to the Current Procedural Terminology (CPT) Manual for additional information about intermediate and comprehensive ophthalmological services Routine Vision Testing Procedure codes S0620 and S0621 may be reimbursed for routine vision testing with refraction when they are billed with diagnosis code Z0100 or Z0101. 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 or contact lenses once every state fiscal year (September 1 through August 31). The limitation for refraction testing can be exceeded for clients who are birth through 20 years of age only when: The parent, teacher, or school nurse requests the refraction testing and it is medically necessary. There is a significant change in vision, and documentation supports a diopter (d) change of 0.5d or greater in the sphere, cylinder, prism measurements, or axis changes. 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 or contact lenses once every two state fiscal years (September 1 through August 31). The limitation for refraction testing can be exceeded for clients who are 21 years of age and older only when there is a significant change in vision, and documentation supports a diopter change of 0.5d or more in the sphere, cylinder, prism measurements, or axis changes Medically Necessary Eye Examinations An eye examination with or without refraction (procedure code 92002, 92004, 92012, 92014, or 92015) may be reimbursed for medical evaluations and examinations of the eye. Procedure codes 92002, 92004, 92012, 92014, and will not be reimbursed for routine exams. Providers must use one of the following diagnosis codes or combination diagnosis codes for medical evaluations and examinations of the eye: Diagnosis Codes Single Diagnosis Codes (Submitted as stand-alone diagnosis codes) A179 A182 A184 A1850 A1851 A1852 A1853 A1854 A1859 A186 A187 A1881 A1884 A1885 A1889 A211 30

31 Diagnosis Codes A238 A239 A281 A300 A301 A303 A305 A308 A309 A35 A3982 A400 A401 A403 A409 A4101 A411 A412 A413 A414 A4150 A4151 A4152 A4153 A4159 A4189 A419 A422 A4289 A429 A438 A439 A480 A483 A488 A4901 A492 A493 A498 A5143 A5430 A5431 A5432 A5433 A5439 A711 A719 A740 A800 A801 A802 A8030 A8039 A804 A809 A8100 A8109 A811 A812 A8181 A8189 A819 B0050 B0053 B0059 B0581 B081 B20 B250 B251 B252 B258 B259 B300 B301 B302 B303 B308 B333 B338 B471 B5801 B5809 B950 B951 B952 B953 B954 B955 B9561 B957 B958 B960 B961 B963 B964 B965 B966 B967 B9681 B9682 B9689 B970 B9711 B9712 B9730 B9733 B9734 B9735 B9739 B977 C6901 C6902 C6911 C6912 C6921 C6922 C6931 C6932 C6941 C6942 C6951 C6952 C6961 C6962 C6981 C6982 C6991 C6992 C7940 C7949 D0921 D0922 D3101 D3102 D3111 D3112 D3121 D3122 D3131 D3132 D3141 D3142 D3151 D3152 D3161 D3162 D3191 D3192 E08311 E08319 E08321 E08329 E08331 E08339 E08341 E08349 E08351 E08359 E0836 E0842 E09311 E09319 E09321 E09329 E09331 E09339 E09341 E09349 E09351 E09359 E0936 E0942 E1010 E1011 E1021 E1022 E1029 E10311 E10319 E10321 E10329 E10331 E10339 E10341 E10349 E10351 E10359 E1036 E1039 E1040 E1041 E1042 E1043 E1044 E1049 E1051 E1052 E1059 E10610 E10618 E10620 E10621 E10622 E10628 E10630 E10638 E10641 E10649 E1065 E1069 E108 E109 E1101 E1121 E1122 E1129 E11311 E11319 E11321 E11329 E11331 E11339 E11341 E11349 E11351 E11359 E1136 E1139 E1140 E1141 E1142 E1143 E1144 E1149 E1151 E1152 E1159 E11610 E11620 E11621 E11622 E11628 E11630 E11638 E11641 E11649 E1165 E1169 E118 E119 E1301 E1310 E1311 E1321 E1322 E1329 E13311 E13319 E13321 E13329 E13331 E13339 E13341 E13349 E13351 E13359 E1336 E1339 E1340 E1341 E1342 E1343 E1344 E1349 E1351 E1352 E1359 E13610 E13641 E138 E139 F6089 G35 G360 G43001 G43009 G43011 G43019 G43101 G43109 G43111 G43119 G43401 G43409 G43411 G43419 G43501 G43509 G43511 G43519 G43601 G43609 G43611 G43619 G43701 G43709 G43711 G43719 G43801 G43809 G43811 G43819 G43821 G43829 G43831 G43839 G43901 G43909 G

32 Diagnosis Codes G43A0 G43A1 G43B0 G43B1 G43C0 G43C1 G43D0 G43D1 G500 G510 G511 G512 G514 G518 G519 G527 G932 H00011 H00012 H00014 H00015 H00021 H00022 H00024 H00025 H00031 H00032 H00034 H00035 H0011 H0012 H0014 H0015 H01001 H01002 H01004 H01005 H01011 H01012 H01014 H01015 H01021 H01022 H01024 H01025 H01111 H01112 H01113 H01114 H01115 H01116 H01119 H01121 H01122 H01124 H01125 H01131 H01132 H01134 H01141 H01142 H01144 H01145 H018 H019 H02001 H02002 H02004 H02005 H02011 H02012 H02014 H02015 H02021 H02022 H02024 H02025 H02031 H02032 H02034 H02035 H02036 H02041 H02042 H02044 H02045 H02051 H02052 H02054 H02055 H02101 H02102 H02104 H02105 H02111 H02112 H02114 H02115 H02121 H02122 H02124 H02125 H02131 H02132 H02134 H02135 H02141 H02142 H02144 H02145 H02201 H02202 H02204 H02205 H02211 H02212 H02214 H02215 H02221 H02222 H02224 H02225 H02231 H02232 H02234 H02235 H0231 H0232 H0234 H0235 H02401 H02402 H02403 H02421 H02422 H02423 H02431 H02432 H02433 H02511 H02512 H02514 H02515 H02521 H02522 H02524 H02525 H02526 H02531 H02532 H02534 H02535 H0259 H0261 H0262 H0264 H0265 H0270 H02711 H02712 H02714 H02715 H02721 H02722 H02724 H02725 H02731 H02732 H02734 H02735 H0279 H02811 H02812 H02813 H02814 H02815 H02816 H02821 H02822 H02824 H02825 H02831 H02832 H02834 H02835 H02841 H02842 H02844 H02845 H02851 H02852 H02854 H02855 H02861 H02862 H02864 H02865 H02871 H02872 H02874 H02875 H0289 H029 H04001 H04002 H04003 H04011 H04012 H04013 H04021 H04022 H04023 H04031 H04032 H04033 H04111 H04112 H04113 H04121 H04122 H04123 H04131 H04132 H04133 H04141 H04142 H04143 H04151 H04152 H04153 H04159 H04161 H04162 H04163 H0419 H04201 H04202 H04203 H04211 H04212 H04213 H04301 H04302 H04303 H04311 H04312 H04313 H04331 H04332 H04333 H04411 H04412 H04413 H04421 H04422 H04423 H04431 H04432 H04433 H04511 H04512 H04513 H04521 H04522 H04523 H04541 H04542 H04543 H04551 H04552 H04553 H04559 H04561 H04562 H04563 H04571 H04572 H04573 H04611 H04612 H04613 H0469 H04811 H04812 H04813 H0489 H0500 H05011 H05012 H05013 H05021 H05022 H05023 H05031 H05032 H05033 H05041 H05042 H05043 H0510 H05111 H05112 H05113 H05121 H05122 H05123 H0520 H05211 H05212 H05213 H05221 H05222 H05223 H05231 H05232 H05233 H05241 H05242 H05243 H

33 Diagnosis Codes H05252 H05253 H05261 H05262 H05263 H0530 H05311 H05312 H05313 H05321 H05322 H05323 H05331 H05332 H05333 H05341 H05342 H05343 H05351 H05352 H05353 H05401 H05402 H05403 H05411 H05412 H05413 H05421 H05422 H05423 H0551 H0552 H0553 H05811 H05812 H05813 H05821 H05822 H05823 H0589 H059 H10011 H10012 H10013 H10021 H10022 H10023 H1011 H1012 H1013 H10211 H10212 H10213 H10221 H10222 H10223 H10231 H10232 H10233 H1031 H1032 H1033 H10401 H10402 H10403 H10411 H10412 H10413 H10421 H10422 H10423 H10431 H10432 H10433 H1044 H1045 H10501 H10502 H10503 H10511 H10512 H10513 H10521 H10522 H10523 H10531 H10532 H10533 H10811 H10812 H10813 H1089 H109 H11001 H11002 H11003 H11011 H11012 H11013 H11021 H11022 H11023 H11031 H11032 H11033 H11041 H11042 H11043 H11051 H11052 H11053 H11061 H11062 H11063 H1110 H11111 H11112 H11113 H11121 H11122 H11123 H11131 H11132 H11133 H11141 H11142 H11143 H11151 H11152 H11153 H11211 H11212 H11213 H11221 H11222 H11223 H11231 H11232 H11233 H11241 H11242 H11243 H1131 H1132 H1133 H11411 H11412 H11413 H11421 H11422 H11423 H11431 H11432 H11433 H11441 H11442 H11443 H11811 H11812 H11813 H11821 H11822 H11823 H1189 H119 H15001 H15002 H15003 H15011 H15012 H15013 H15021 H15022 H15023 H15031 H15032 H15033 H15041 H15042 H15043 H15051 H15052 H15053 H15091 H15092 H15093 H15101 H15102 H15103 H15111 H15112 H15113 H15121 H15122 H15123 H15811 H15812 H15813 H15821 H15822 H15823 H15831 H15832 H15833 H15841 H15842 H15843 H15851 H15852 H15853 H1589 H159 H16001 H16002 H16003 H16011 H16012 H16013 H16021 H16022 H16023 H16031 H16032 H16033 H16041 H16042 H16043 H16051 H16052 H16053 H16061 H16062 H16063 H16071 H16072 H16073 H16101 H16102 H16103 H16111 H16112 H16113 H16121 H16122 H16123 H16131 H16132 H16133 H16141 H16142 H16143 H16201 H16202 H16203 H16211 H16212 H16213 H16221 H16222 H16223 H16231 H16232 H16233 H16241 H16242 H16243 H16251 H16252 H16253 H16261 H16262 H16263 H16291 H16292 H16293 H16301 H16302 H16303 H16311 H16312 H16313 H16321 H16322 H16323 H16331 H16332 H16333 H16391 H16392 H16393 H16401 H16402 H16403 H16411 H16412 H16413 H16421 H16422 H16423 H16431 H16432 H16433 H16441 H16442 H16443 H168 H169 H1701 H1702 H1703 H1711 H1712 H1713 H17811 H17812 H17813 H17821 H17822 H17823 H

34 Diagnosis Codes H179 H18001 H18002 H18003 H18011 H18012 H18013 H18021 H18022 H18023 H18031 H18032 H18033 H18041 H18042 H18043 H18051 H18052 H18053 H18061 H18062 H18063 H1811 H1812 H1813 H1820 H18211 H18212 H18213 H18221 H18222 H18223 H18231 H18232 H18233 H1830 H18311 H18312 H18313 H18321 H18322 H18323 H18331 H18332 H18333 H1840 H18411 H18412 H18413 H18421 H18422 H18423 H1843 H18441 H18442 H18443 H18451 H18452 H18453 H18461 H18462 H18463 H1849 H1850 H1851 H1852 H1853 H1854 H1855 H1859 H18601 H18602 H18603 H18611 H18612 H18613 H18621 H18622 H18623 H18711 H18712 H18713 H18721 H18722 H18723 H18731 H18732 H18733 H18739 H18811 H18812 H18813 H18821 H18822 H18823 H18831 H18832 H18833 H18891 H18892 H18893 H189 H2000 H20011 H20012 H20013 H20021 H20022 H20023 H20031 H20032 H20033 H20041 H20042 H20043 H20051 H20052 H20053 H2011 H2012 H2013 H2021 H2022 H2023 H20811 H20812 H20813 H20821 H20822 H20823 H209 H2101 H2102 H2103 H211X1 H211X2 H211X3 H21211 H21212 H21213 H21221 H21222 H21223 H21231 H21232 H21233 H21241 H21242 H21243 H21251 H21252 H21253 H21261 H21262 H21263 H21271 H21272 H21273 H2129 H21301 H21302 H21303 H21311 H21312 H21313 H21321 H21322 H21323 H21341 H21342 H21343 H21351 H21352 H21353 H2141 H2142 H2143 H21501 H21502 H21503 H21511 H21512 H21513 H21521 H21522 H21523 H21531 H21532 H21533 H21541 H21542 H21543 H21551 H21552 H21553 H21561 H21562 H21563 H2181 H2182 H2189 H219 H22 H25011 H25012 H25013 H25031 H25032 H25033 H25041 H25042 H25043 H25091 H25092 H25093 H2511 H2512 H2513 H2521 H2522 H2523 H25811 H25812 H25813 H2589 H259 H26001 H26002 H26003 H26011 H26012 H26013 H26031 H26032 H26033 H26041 H26042 H26043 H26051 H26052 H26053 H26061 H26062 H26063 H2609 H26101 H26102 H26103 H26111 H26112 H26113 H26121 H26122 H26123 H26131 H26132 H26133 H2620 H26211 H26212 H26213 H26221 H26222 H26223 H26231 H26232 H26233 H2631 H2632 H2633 H2640 H26411 H26412 H26413 H26491 H26492 H26493 H268 H269 H2701 H2702 H2703 H27111 H27112 H27113 H27121 H27122 H27123 H27131 H27132 H27133 H278 H279 H28 H30001 H30002 H30003 H30011 H30012 H30013 H30021 H30022 H30023 H30031 H30032 H30033 H30041 H30042 H30043 H30101 H30102 H30103 H30111 H30112 H30113 H30121 H30122 H30123 H30131 H

35 Diagnosis Codes H30133 H30141 H30142 H30143 H3021 H3022 H3023 H30811 H30812 H30813 H30891 H30892 H30893 H3091 H3092 H3093 H31001 H31002 H31003 H31011 H31012 H31013 H31021 H31022 H31023 H31091 H31092 H31093 H31101 H31102 H31103 H31111 H31112 H31113 H31121 H31122 H31123 H31129 H3120 H3121 H3122 H3123 H3129 H31301 H31302 H31303 H31311 H31312 H31313 H31321 H31322 H31323 H31401 H31402 H31403 H31411 H31412 H31413 H31419 H31421 H31422 H31423 H318 H319 H33001 H33002 H33003 H33011 H33012 H33013 H33021 H33022 H33023 H33031 H33032 H33033 H33041 H33042 H33043 H33051 H33052 H33053 H33101 H33102 H33103 H33111 H33112 H33113 H33119 H33191 H33192 H33193 H3321 H3322 H3323 H33301 H33302 H33303 H33311 H33312 H33313 H33321 H33322 H33323 H33331 H33332 H33333 H3341 H3342 H3343 H338 H3401 H3402 H3403 H3411 H3412 H3413 H34211 H34212 H34213 H34231 H34232 H34233 H34811 H34812 H34813 H34821 H34822 H34823 H34831 H34832 H34833 H349 H3500 H35011 H35012 H35013 H35021 H35022 H35023 H35031 H35032 H35033 H35041 H35042 H35043 H35051 H35052 H35053 H35061 H35062 H35063 H35071 H35072 H35073 H3509 H35101 H35102 H35103 H35111 H35112 H35113 H35121 H35122 H35123 H35131 H35132 H35133 H35141 H35142 H35143 H35151 H35152 H35153 H35161 H35162 H35163 H35171 H35172 H35173 H3521 H3522 H3523 H3530 H3531 H3532 H3533 H35341 H35342 H35343 H35351 H35352 H35353 H35361 H35362 H35363 H35371 H35372 H35373 H35381 H35382 H35383 H3540 H35411 H35412 H35413 H35421 H35422 H35423 H35431 H35432 H35433 H35441 H35442 H35443 H35451 H35452 H35453 H35461 H35462 H35463 H3550 H3551 H3552 H3553 H3554 H3561 H3562 H3563 H3570 H35711 H35712 H35713 H35721 H35722 H35723 H35731 H35732 H35733 H3581 H3582 H3589 H359 H36 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 H40143 H H H H H H H H H H H H

36 Diagnosis Codes 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 H4040X4 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 H40831 H40832 H40833 H4089 H409 H42 H4301 H4302 H4303 H4311 H4312 H4313 H4321 H4322 H4323 H43311 H43312 H43313 H43391 H43392 H43393 H43811 H43812 H43813 H43821 H43822 H43823 H4389 H439 H44001 H44002 H44003 H44011 H44012 H44013 H44021 H44022 H44023 H44111 H44112 H44113 H44121 H44122 H44123 H44131 H44132 H44133 H4419 H4421 H4422 H4423 H4430 H44311 H44312 H44313 H44319 H44321 H44322 H44323 H44391 H44392 H44393 H4440 H44411 H44412 H44413 H44421 H44422 H44423 H44431 H44432 H44433 H44441 H44442 H44443 H44449 H4450 H44511 H44512 H44513 H44521 H44522 H44523 H44531 H44532 H44533 H44601 H44602 H44603 H44611 H44612 H44613 H44621 H44622 H44623 H44631 H44632 H44633 H44641 H44642 H44643 H44651 H44652 H44653 H44691 H44692 H44693 H44701 H44702 H44703 H44711 H44712 H44713 H44721 H44722 H44723 H44731 H44732 H44733 H44741 H44742 H44743 H44751 H44752 H44753 H44791 H44792 H44793 H44811 H44812 H44813 H44821 H44822 H44823 H4489 H449 H4601 H4602 H4603 H4611 H4612 H4613 H462 H463 H468 H469 H47011 H47012 H47013 H47021 H47022 H47023 H47031 H47032 H47033 H47091 H47092 H47093 H4710 H4711 H4712 H4713 H47141 H47142 H47143 H4720 H47211 H47212 H47213 H4722 H47231 H47232 H47233 H47291 H47292 H47293 H47311 H47312 H47313 H47321 H47322 H47323 H47331 H47332 H47333 H47391 H47392 H47393 H4741 H4742 H4743 H4749 H47511 H47512 H47521 H47522 H47531 H47532 H47611 H47612 H47621 H47622 H47631 H47632 H47641 H47642 H479 H4901 H4902 H4903 H4911 H4912 H4913 H4921 H4922 H4923 H4931 H4932 H4933 H

37 Diagnosis Codes H4942 H4943 H49889 H499 H5000 H50011 H50012 H50021 H50022 H50031 H50032 H50041 H50042 H5005 H5006 H5007 H5008 H5010 H50111 H50112 H50121 H50122 H50131 H50132 H50141 H50142 H5015 H5016 H5017 H5018 H5021 H5022 H5030 H50311 H50312 H5032 H50331 H50332 H5034 H5040 H50411 H50412 H5042 H5043 H5050 H5051 H5052 H5053 H5054 H5055 H5060 H50611 H50612 H5069 H50811 H50812 H5089 H510 H5111 H5112 H5121 H5122 H5123 H518 H519 H5201 H5202 H5203 H5211 H5212 H5213 H52201 H52202 H52203 H52211 H52212 H52213 H52221 H52222 H52223 H5231 H5232 H524 H52511 H52512 H52513 H52519 H52521 H52522 H52523 H52531 H52532 H52533 H526 H527 H53001 H53002 H53003 H53011 H53012 H53013 H53021 H53022 H53023 H53031 H53032 H53033 H5310 H5311 H53121 H53122 H53123 H53131 H53132 H53133 H53141 H53142 H53143 H53149 H5315 H5316 H5319 H532 H5330 H5331 H5332 H5333 H5334 H5340 H53411 H53412 H53413 H53421 H53422 H53423 H53431 H53432 H53433 H53451 H53452 H53453 H53461 H53462 H5347 H53481 H53482 H53483 H5350 H5351 H5352 H5353 H5354 H5355 H5359 H5360 H5361 H5362 H5363 H5369 H5371 H5372 H538 H539 H543 H5441 H5442 H5461 H5462 H547 H548 H5500 H5501 H5502 H5503 H5504 H5509 H5581 H5589 H5700 H5701 H5702 H5703 H5704 H57051 H57052 H57053 H5711 H5712 H5713 H578 H579 H59021 H59022 H59023 H59091 H59092 H59093 H5988 H5989 I10 K9081 L121 L510 L511 L512 L513 L518 L519 L631 L632 L638 L639 L648 L651 L652 L658 L660 L662 L668 L669 L718 L719 M320 M3210 M3219 M328 M329 M3500 M3501 M3509 M60009 P113 P158 Q100 Q101 Q102 Q103 Q104 Q105 Q106 Q107 Q110 Q111 Q112 Q120 Q121 Q122 Q123 Q124 Q128 Q130 Q131 Q132 Q133 Q134 Q135 Q1381 Q1389 Q140 Q141 Q142 Q143 Q148 Q150 Q158 Q159 Q752 Q840 Q841 Q842 R29891 R42 R483 R51 S0011XA S0011XD S0011XS S0012XA S0012XD S0012XS S00211A S00211D S00211S S00212A S00212D S00212S S00221A S00221D S00221S S00222A S00222D S00222S S00241A S00241D S00241S S00242A S00242D S00242S S00251A S00251D S00251S S00252A S00252D S00252S S00261A S00261D S00261S S00262A S00262D S00262S S00271A S00271D S00271S S00272A S00272D S00272S S01101A S01101D S01101S S01102A 37

38 Diagnosis Codes S01102D S01102S S01111A S01111D S01111S S01112A S01112D S01112S S01121A S01121D S01121S S01122A S01122D S01122S S01129A S01131A S01131D S01131S S01132A S01132D S01132S S01141A S01141D S01141S S01142A S01142D S01142S S01151A S01151D S01151S S01152A S01152D S01152S S01159A S04011A S04011D S04011S S04012A S04012D S04012S S0402XA S0402XD S0402XS S04031A S04031D S04031S S04032A S04032D S04032S S04041A S04041D S04041S S04042A S04042D S04042S S0411XA S0411XD S0411XS S0412XA S0412XD S0412XS S0421XA S0421XD S0421XS S0422XA S0422XD S0422XS S0431XA S0431XD S0431XS S0432XA S0432XD S0432XS S0441XA S0441XD S0441XS S0442XA S0442XD S0442XS S0451XA S0451XD S0451XS S0452XA S0452XD S0452XS S0461XS S0462XS S0471XS S0472XS S04811S S04812S S04891S S04892S S0501XA S0501XD S0501XS S0502XA S0502XD S0502XS S0511XA S0511XD S0511XS S0512XA S0512XD S0512XS S0521XA S0521XD S0521XS S0522XA S0522XD S0522XS S0531XA S0531XD S0531XS S0532XA S0532XD S0532XS S0540XA S0540XD S0540XS S0541XA S0541XD S0541XS S0542XA S0542XD S0542XS S0551XA S0551XD S0551XS S0552XA S0552XD S0552XS S0561XA S0561XD S0561XS S0562XA S0562XD S0562XS S0571XA S0571XD S0571XS S0572XA S0572XD S0572XS S058X1A S058X1D S058X1S S058X2A S058X2D S058X2S S0591XA S0591XD S0591XS S0592XA S0592XD S0592XS T1501XA T1501XD T1501XS T1502XA T1502XD T1502XS T1511XA T1511XD T1511XS T1512XA T1512XD T1512XS T1581XA T1581XD T1581XS T1582XA T1582XD T1582XS T1591XA T1591XD T1591XS T1592XA T1592XD T1592XS T2000XA T2000XD T2000XS T2009XA T2009XD T2009XS T2010XA T2010XD T2010XS T2019XA T2019XD T2019XS T2020XA T2020XD T2020XS T2029XA T2029XD T2029XS T2030XA T2030XD T2030XS T2039XA T2039XD T2039XS T2059XA T2059XD T2059XS T2601XA T2601XD T2601XS T2602XA T2602XD T2602XS T2611XA T2611XD T2611XS T2612XA T2612XD T2612XS T2621XA T2621XD T2621XS T2622XA T2622XD T2622XS T2631XA T2631XD T2631XS T2632XA T2632XD T2632XS T2641XA T2641XD T2641XS T2642XA T2642XD T2642XS T2651XA T2651XD T2651XS T2652XA T2652XD T2652XS T2661XA T2661XD T2661XS T2662XA T2662XD T2662XS T2671XA T2671XD T2671XS T2672XA T2672XD T2672XS T2691XA T2691XD T2691XS T2692XA T2692XD T2692XS T360X5S T361X5S T362X5S T363X5S T364X5S T365X5S T366X5S T367X5S T368X5S T3695XS T370X5S T371X5S T372X5S T373X5S T374X5S T375X5S T378X5S T3795XS T380X5S T381X5S T382X5S T383X5S T384X5S T385X5S T386X5S T387X5S T38805S T38815S T38895S T38905S T38995S T39015S T39095S T391X5S T392X5S T39315S T39395S T394X5S T398X5S T3995XS T400X5S T401X5S T402X5S T403X5S T404X5S T405X5S T40605S T40695S T407X5S T408X5S T40905S T40995S T410X5S T411X5S T41205S T41295S T413X5S T4145XS T415X5S 38

39 Diagnosis Codes T420X5S T421X5S T422X5S T423X5S T424X5S T425X5S T426X5S T4275XS T428X5S T43015S T43025S T431X5S T43205S T43215S T43225S T43295S T433X5S T434X5S T43505S T43595S T43605S T43615S T43625S T43635S T43695S T438X5S T4395XS T440X5S T441X5S T442X5S T443X5S T444X5S T445X5S T446X5S T447X5S T448X5S T44905S T44995S T450X5S T451X5S T452X5S T453X5S T454X5S T45515S T45525S T45605S T45615S T45625S T45695S T457X5S T458X5S T4595XS T460X5S T461X5S T462X5S T463X5S T464X5S T465X5S T466X5S T467X5S T468X5S T46905S T46995S T470X5S T471X5S T472X5S T473X5S T474X5S T475X5S T476X5S T477X5S T478X5S T4795XS T480X5S T481X5S T48205S T48295S T483X5S T484X5S T485X5S T486X5S T48905S T48995S T490X5S T491X5S T492X5S T493X5S T494X5S T495X1A T495X1D T495X1S T495X2A T495X2D T495X2S T495X3A T495X3D T495X3S T495X4A T495X4D T495X4S T495X5S T496X5S T497X5S T498X5S T4995XS T500X5S T501X5S T502X5S T503X5S T504X5S T505X5S T506X5S T507X5S T508X5S T50905S T50995S T50A15S T50A25S T50A95S T50B15S T50B95S T50Z15S T50Z95S T8131XA T8131XD T8131XS T8132XA T8132XD T8132XS T814XXA T814XXD T814XXS T8183XA T8183XD T8183XS T8189XA T8189XD T8189XS T819XXA T819XXD T819XXS T8521XA T8521XD T8521XS T8522XA T8522XD T8522XS T8529XA T8529XD T8529XS T85310A T85310D T85310S T85311A T85311D T85311S T85318A T85318D T85318S T85320A T85320D T85320S T85321A T85321D T85321S T85328A T85328D T85328S T85390A T85390D T85390S T85391A T85391D T85391S T85398A T85398D T85398S T8579XA T8579XD T8579XS T8581XA T8581XD T8581XS T8582XA T8582XD T8582XS T8583XA T8583XD T8583XS T8584XA T8584XD T8584XS T8585XA T8585XD T8585XS T8586XA T8586XD T8586XS T8589XA T8589XD T8589XS T886XXS T887XXS Z0389 Z09 Z1289 Z4421 Z4422 Z48810 Z5189 Z525 Z7901 Z7902 Z791 Z792 Z793 Z794 Z7951 Z7952 Z79810 Z79811 Z79818 Z7982 Z7983 Z79891 Z79899 Z9001 Z947 Z961 Z970 Z9841 Z9842 Z9849 Z9883 Combination Diagnosis Codes (Must be submitted in pairs) B394 H32 E10311 E1065 E1121 E1165 B395 H32 E10319 E1065 E11311 E1165 B399 H32 E1051 E1065 E11319 E1165 E1010 E1065 E1069 E1065 E1136 E1165 E1021 E1065 E108 E1065 E1139 E1165 E1036 E1065 E118 E1165 E1140 E1165 E1039 E1065 E1100 E1165 E1151 E1165 Documentation in the client s medical record must support the medical necessity of the service performed. E1040 E1065 E1101 E1165 E1169 E

40 Procedure codes 92002, 92004, 92012, 92014, and may be reimbursed as often as is medically necessary to ophthalmologist or optometrist providers for medically necessary eye examinations without refraction. Procedure code may be reimbursed to ophthalmologist or optometrist providers for refraction in addition to the eye examination procedure code 92002, 92004, 92012, or A refractive state (procedure code 92015) will be denied as part of another service if it is billed with the same date of service by the same provider as procedure code S0620 or S Ophthalmological Examination and Evaluation with General Anesthesia An ophthalmological examination and evaluation under general anesthesia (procedure codes and 92019) may be medically necessary when a client has significant injury or cannot otherwise tolerate the procedure while conscious. Procedure codes and may be reimbursed once per service, per day, when billed by any provider Ophthalmic Ultrasound Ophthalmic ultrasound is an ultrasonic diagnostic test that uses high frequency sound waves that are used to provide additional information about the interior of the eye and surrounding areas. The following procedure codes may be reimbursed for ophthalmic ultrasound services: Procedure Codes One of the following diagnosis codes or combination diagnosis codes must be submitted with the most appropriate ophthalmic ultrasound procedure code: Diagnosis Codes Single Diagnosis Codes (Submitted as stand-alone diagnosis codes) A1859 C6941 C6942 C6961 C6962 C7940 C7949 D0921 D0922 D3141 D3142 D3161 D3162 D487 D4981 E08311 E08319 E08321 E08329 E08331 E08339 E08341 E08349 E08351 E08359 E0836 E0839 E0840 E0841 E0842 E0843 E0844 E0849 E0851 E0859 E08610 E08618 E08620 E08621 E08622 E08628 E08630 E08638 E08649 E0865 E0869 E088 E09311 E09319 E09321 E09329 E09331 E09339 E09341 E09349 E09351 E09359 E0936 E0939 E0940 E0941 E0942 E0943 E0944 E0949 E0951 E0959 E09610 E09618 E09620 E09621 E09622 E09628 E09630 E09638 E09649 E0965 E0969 E098 E10311 E10319 E10321 E10329 E10331 E10339 E10341 E10349 E10351 E10359 E1036 E1039 E11311 E11319 E11321 E11329 E11331 E11339 E11341 E11349 E11351 E11359 E1136 E1139 E13311 E13319 E13321 E13329 E13331 E13339 E13341 E13349 E13351 E13359 E1336 E1339 E1340 E1341 E1342 E1343 E1344 E1349 E1359 E13610 E13620 E13621 E13622 E13628 E13638 E13649 E1365 E1369 E138 H02813 H02816 H04151 H04152 H04153 H04159 H0551 H0552 H0553 H1701 H1702 H

41 Diagnosis Codes H1711 H1712 H1713 H17811 H17812 H17813 H17821 H17822 H17823 H1789 H179 H18001 H18002 H18003 H18011 H18012 H18013 H18021 H18022 H18023 H18031 H18032 H18033 H18041 H18042 H18043 H18051 H18052 H18053 H18061 H18062 H18063 H1811 H1812 H1813 H1820 H18211 H18212 H18213 H18221 H18222 H18223 H18231 H18232 H18233 H1830 H18311 H18312 H18313 H18321 H18322 H18323 H18331 H18332 H18333 H1840 H18411 H18412 H18413 H18421 H18422 H18423 H1843 H18441 H18442 H18443 H18451 H18452 H18453 H18461 H18462 H18463 H1849 H1850 H1851 H1852 H1853 H1854 H1855 H1859 H18601 H18602 H18603 H18611 H18612 H18613 H18621 H18622 H18623 H1870 H18711 H18712 H18713 H18721 H18722 H18723 H18731 H18732 H18733 H18739 H18791 H18792 H18793 H18811 H18812 H18813 H18821 H18822 H18823 H18831 H18832 H18833 H18891 H18892 H18893 H189 H2101 H2102 H2103 H2181 H2182 H2189 H22 H25011 H25012 H25013 H25031 H25032 H25033 H25041 H25042 H25043 H25091 H25092 H25093 H2511 H2512 H2513 H2521 H2522 H2523 H25811 H25812 H25813 H2589 H259 H26001 H26002 H26003 H26011 H26012 H26013 H26031 H26032 H26033 H26041 H26042 H26043 H26051 H26052 H26053 H26061 H26062 H26063 H2609 H26101 H26102 H26103 H26111 H26112 H26113 H26121 H26122 H26123 H26131 H26132 H26133 H2620 H26211 H26212 H26213 H26221 H26222 H26223 H26231 H26232 H26233 H2631 H2632 H2633 H2640 H26411 H26412 H26413 H26491 H26492 H26493 H268 H269 H2701 H2702 H2703 H27111 H27112 H27113 H27121 H27122 H27123 H27131 H27132 H27133 H278 H279 H28 H31101 H31102 H31103 H31111 H31112 H31113 H31121 H31122 H31123 H31129 H3123 H31301 H31302 H31303 H31311 H31312 H31313 H31321 H31322 H31323 H31401 H31402 H31403 H31411 H31412 H31413 H31419 H31421 H31422 H31423 H33001 H33002 H33003 H33011 H33012 H33013 H33021 H33022 H33023 H33031 H33032 H33033 H33041 H33042 H33043 H33051 H33052 H33053 H33101 H33102 H33103 H33111 H33112 H33113 H33119 H33191 H33192 H33193 H3321 H3322 H3323 H33301 H33302 H33303 H33311 H33312 H33313 H33321 H33322 H33323 H33331 H33332 H33333 H3341 H3342 H3343 H338 H3401 H3402 H3403 H3411 H3412 H3413 H34211 H34212 H34213 H34231 H34232 H34233 H34811 H34812 H34813 H34821 H34822 H34823 H34831 H34832 H34833 H349 H3500 H35011 H35012 H35013 H35021 H35022 H

42 Diagnosis Codes H35031 H35032 H35033 H35041 H35042 H35043 H35051 H35052 H35053 H35061 H35062 H35063 H35071 H35072 H35073 H3509 H35101 H35102 H35103 H35111 H35112 H35113 H35121 H35122 H35123 H35131 H35132 H35133 H35141 H35142 H35143 H35151 H35152 H35153 H35161 H35162 H35163 H35171 H35172 H35173 H3521 H3522 H3523 H3530 H3531 H3532 H3533 H35341 H35342 H35343 H35351 H35352 H35353 H35361 H35362 H35363 H35371 H35372 H35373 H35381 H35382 H35383 H3540 H35411 H35412 H35413 H35421 H35422 H35423 H35431 H35432 H35433 H35441 H35442 H35443 H35451 H35452 H35453 H35461 H35462 H35463 H3550 H3551 H3552 H3553 H3554 H3561 H3562 H3563 H3570 H35711 H35712 H35713 H35721 H35722 H35723 H35731 H35732 H35733 H3581 H3582 H3589 H36 H4301 H4302 H4303 H43811 H43812 H43813 H44601 H44602 H44603 H44611 H44612 H44613 H44621 H44622 H44623 H44631 H44632 H44633 H44641 H44642 H44643 H44651 H44652 H44653 H44691 H44692 H44693 H44701 H44702 H44703 H44711 H44712 H44713 H44721 H44722 H44723 H44731 H44732 H44733 H44741 H44742 H44743 H44751 H44752 H44753 H44791 H44792 H44793 H578 Q120 Q121 Q122 Q123 Q124 Q128 S0551XA S0551XD S0551XS S0552XA S0552XD S0552XS T1501XA T1501XD T1501XS T1502XA T1502XD T1502XS T1511XA T1511XD T1511XS T1512XA T1512XD T1512XS T1581XA T1581XD T1581XS T1582XA T1582XD T1582XS T1591XA T1591XD T1591XS T1592XA T1592XD T1592XS Combination Diagnosis Codes (Must be submitted in pairs) E0821 E0865 E0921 E0865 E10311 E1065 E08311 E0865 E09311 E0865 E10319 E1065 E08319 E0865 E09319 E0865 E1036 E1065 E0836 E0865 E0936 E0865 E1039 E1065 E0840 E0865 E0940 E0865 E11311 E1165 E0851 E0865 E0951 E0865 E11319 E1165 E0869 E0865 E0969 E0865 E1136 E1165 E088 E0865 E098 E0865 E1139 E1165 Procedure code may be reimbursed once per lifetime or as medically necessary as indicated when billed with one of the diagnosis codes in the following table: Diagnosis Codes (Submitted as stand-alone diagnosis codes) Once Per Lifetime 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

43 Diagnosis Codes (Submitted as stand-alone diagnosis codes) H H H H H H H H H H H H H H H H H H H H H H40141 H40142 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 H40831 H40832 H40833 H4089 H409 H42 H44511 H44512 H44513 Q150 As Medically Necessary A1859 H1701 H1702 H1703 H1711 H1712 H1713 H17811 H17812 H17813 H17821 H17822 H17823 H1789 H179 H18001 H18002 H18003 H18011 H18012 H18013 H18021 H18022 H18023 H18031 H18032 H18033 H18041 H18042 H18043 H18051 H18052 H18053 H18061 H18062 H18063 H1811 H1812 H1813 H1820 H18211 H18212 H18213 H18221 H18222 H18223 H18231 H18232 H18233 H1830 H18311 H18312 H18313 H18321 H18322 H18323 H18331 H18332 H18333 H1840 H18411 H18412 H18413 H18421 H18422 H18423 H1843 H18441 H18442 H18443 H18451 H18452 H18453 H18461 H18462 H18463 H1849 H1850 H1851 H1852 H1853 H1854 H1855 H1859 H18601 H18602 H18603 H18611 H18612 H18613 H18621 H18622 H18623 H1870 H18711 H18712 H18713 H18791 H18792 H18793 H18831 H18832 H18833 H21551 H21552 H21553 H4040X4 H4041X0 H4041X1 H4041X2 H4041X3 H4041X4 H4042X0 H4042X1 H4042X2 H4042X3 H4042X4 H4043X0 H4043X1 H4043X2 H4043X3 H4043X4 H4720 H47211 H47212 H47213 H4722 H47231 H47232 H47233 H47291 H47292 H47293 H5201 H5202 H5203 Q133 Q134 Q150 T85310A T85310D T85310S T85311A T85311D T85311S T85318A T85318D T85318S T85320A T85320D T85320S T85321A T85321D T85321S T85328A T85328D T85328S T85390A T85390D T85390S 43

44 Diagnosis Codes (Submitted as stand-alone diagnosis codes) T85391A T85391D T85391S T85398A T85398D T85398S Z48810 Z947 Procedure code may be reimbursed for locating a foreign body in the eye. Procedure code may be reimbursed with prior authorization. Ophthalmic ultrasounds may be reimbursed when they are billed with the same date of service by the same provider as an eye examination visit or consultation. Ophthalmic ultrasounds (procedure codes and 76516) are limited to one service, per day, by any provider. Procedure codes 92002, 92004, 92012, 92014, and will not be reimbursed for routine exams. Procedure code may be reimbursed as follows: The professional interpretation component may be reimbursed when procedure code is billed with modifier LT or RT to identify the eye on which the service was performed. The technical component may be reimbursed once when the service is performed on one or both eyes on the same date of service by the any provider. The total component may be reimbursed along with an additional professional service when the service is performed on both eyes on the same date of service by the any provider. The claim for the additional interpretation component must include modifier LT or RT. Ophthalmic ultrasound procedure codes are subject to CMS NCCI relationships, except for procedure code 76511, which will be denied when it is billed with the same date of service by the same provider as procedure code Refer to: The CMS NCCI web page for the published correct coding guidelines and specific applicable code combinations. Prior Authorization Requirements Procedure code requires prior authorization. The provider must submit the following documentation with the request: A clear, concise description of the ophthalmic ultrasound being performed. A procedure code that is comparable to the ophthalmic ultrasound being requested or the provider s intended fee for performing the ophthalmic ultrasound. Note: Services and procedures that are investigational or experimental are not a benefit of Texas Medicaid Corneal Topography Procedure code may be reimbursed for corneal topography when it is billed with one of the following diagnosis codes: Diagnosis Codes H10811 H10812 H10813 H11001 H11002 H11003 H11011 H11012 H11013 H11021 H11022 H11023 H11031 H11032 H11033 H11041 H11042 H11043 H11051 H11052 H11053 H11061 H11062 H11063 H11821 H11822 H11823 H1189 H16001 H16002 H16003 H16011 H16012 H16013 H16021 H16022 H16023 H16031 H16032 H16033 H16041 H16042 H16043 H16051 H16052 H16053 H16061 H16062 H16063 H16071 H16072 H16073 H1701 H1702 H1703 H

45 Diagnosis Codes H1712 H1713 H17811 H17812 H17813 H17821 H17822 H17823 H1789 H179 H1811 H1812 H1813 H1820 H18221 H18222 H18223 H18231 H18232 H18233 H1840 H18411 H18412 H18413 H18451 H18452 H18453 H18461 H18462 H18463 H1849 H18601 H18602 H18603 H18611 H18612 H18613 H18621 H18622 H18623 H1870 H18711 H18712 H18713 H18721 H18722 H18723 H18731 H18732 H18733 H18739 H18791 H18792 H18793 H18831 H18832 H18833 S0521XA S0521XD S0521XS S0522XA S0522XD S0522XS S0531XA S0531XD S0531XS S0532XA S0532XD S0532XS T2611XA T2611XD T2611XS T2612XA T2612XD T2612XS T2661XA T2661XD T2661XS T2662XA T2662XD T2662XS T85310A T85310D T85310S T85311A T85311D T85311S T85318A T85318D T85318S T85320A T85320D T85320S T85321A T85321D T85321S T85328A T85328D T85328S T85390A T85390D T85390S T85391A T85391D T85391S T85398A T85398D T85398S Z48810 Z947 Z9841 Z9842 Z9849 Z9883 Corneal topography may be reimbursed when it is billed with the same date of services by the same provider as an eye examination visit or consultation. Corneal topography (procedure code 92025) is limited to one service, per day, by any provider Sensorimotor Examination A sensorimotor examination with interpretation and report consists of multiple ocular deviation measurements and includes, but is not limited to, visual motor integration, reversal frequency (letters and numbers), motor speed and precision, visual memory, and visualization to test eye movement and control, focusing ability, eye teaming ability, depth perception, and visual perception skills. Procedure code may be reimbursed for a sensorimotor examination when it is billed with one of the following diagnosis codes: Diagnosis Codes H50011 H50012 H50021 H50022 H50031 H50032 H50041 H50042 H5005 H5006 H5007 H5008 H50111 H50112 H50121 H50122 H50131 H50132 H50141 H50142 H5015 H5016 H5017 H5018 H5021 H5022 H50311 H50312 H5032 H50331 H50332 H5034 H50411 H50412 H5042 H5043 H5051 H5052 H5053 H5054 H5055 H50611 H50612 H5069 H50811 H50812 H5089 H5111 H5112 H518 H53011 H53012 H53013 H53021 H53022 H53023 H53031 H53032 H53033 H5501 H5502 H5503 H5504 H5509 H5581 H5589 Procedure code may be reimbursed once per day and twice per calendar year when it is billed by any provider and may be reimbursed in addition to an eye examination visit. 45

46 Orthoptic or Pleoptic Training Orthoptics, a component of vision training or vision therapy, are exercises designed to improve the function of the eye muscles with an emphasis on binocular vision and eye movements. Pleoptics are exercises designed to improve impaired vision when there is no evidence of organic eye diseases. Procedure code may be reimbursed for orthoptic or pleoptic training when it is billed with one of the following diagnosis codes: Diagnosis Codes H50011 H50012 H50021 H50022 H50031 H50032 H50041 H50042 H5005 H5006 H5007 H5008 H50111 H50112 H50121 H50122 H50131 H50132 H50141 H50142 H5015 H5016 H5017 H5018 H5021 H5022 H50311 H50312 H5032 H50331 H50332 H5034 H50411 H50412 H5042 H5043 H5051 H5052 H5053 H5054 H5055 H50611 H50612 H5069 H50811 H50812 H5089 H5111 H5112 H518 H53011 H53012 H53013 H53021 H53022 H53023 H53031 H53032 H53033 H5501 H5502 H5503 H5504 H5509 H5581 H5589 Orthoptic or pleoptic training may be reimbursed one service per day for up to 6 services when it is billed with one of the diagnosis codes in the above diagnosis table. Up to an additional 6 services may be reimbursed with prior authorization for a total of 12 services per lifetime. The provider must attest that current therapy has resulted in an improvement with presenting symptomatology over the course of treatment, including, but not limited to: Blurred vision Double vision Amblyopia Accommodation or near point of convergence measurements Note: Orthoptic or pleoptic training services over the 12 per lifetime limit may be considered with prior authorization through CCP for clients who are birth through 20 years of age. Documentation for medical necessity must be submitted with the prior authorization request. Procedure code may be reimbursed in addition to an eye examination visit Ophthalmoscopy, Angioscopy or Angiography Routine ophthalmoscopy is part of general and special ophthalmologic services whenever indicated and may be reimbursed using the following procedure codes: Procedure Codes Ophthalmoscopy and fluorescein angioscopy or angiography (procedure codes 92225, 92226, 92230, and 92235) are considered unilateral procedures and may be reimbursed for a quantity of two if both the left and right eyes are evaluated. If two services are billed for the same date of service, one may be reimbursed at the full rate, and the other may be reimbursed at half rate. Procedure codes and may be reimbursed once per eye, per day when they are billed by any provider. 46

47 Procedure codes and must be billed with modifier LT or RT to identify the eye on which the service was performed. Ophthalmoscopy, angioscopy, and angiography procedure codes are subject to CMS NCCI relationships. In addition to CMS NCCI relationships, the procedure codes in Column A of the following table will be denied if they are billed with the same date of service by the same provider as the corresponding procedure codes in Column B: Column A (Denied) Column B 92132, 92133, , Refer to: The CMS NCCI web page for the published correct coding guidelines and specific applicable code combinations Other Professional Services The following procedure codes may be reimbursed by Texas Medicaid when the services are medically necessary: Procedure Codes Procedure codes and may each be reimbursed once per day. Visual field examination procedure codes 92081, 92082, may be reimbursed twice per calendar year when billed by any provider. Procedure codes 92132, 92133, and may be reimbursed once per day, when it is billed by any provider. Serial automounter (procedure code 92100), ophthalmic biometry (procedure code 92136), and provocative tests for glaucoma (procedure code 92140) may be reimbursed once per day when they are billed by any provider. External ocular photography (procedure code 92285) may be reimbursed once per day, when it is billed by any provider. Procedure codes 92285, 92286, and may be reimbursed when they are billed with one of the following diagnosis codes or combination diagnosis codes: Diagnosis Codes Single Diagnosis Codes (Submitted as stand-alone diagnosis codes) A000 A001 A009 A179 A1803 A182 A184 A1850 A1851 A1852 A1853 A1854 A1859 A186 A187 A1881 A1884 A1885 A1889 A211 A230 A231 A232 A233 A238 A239 A240 A281 A300 A301 A303 A305 A308 A309 A35 A3686 A3982 A400 A401 A403 A409 A4101 A411 A412 A413 A414 A4150 A4151 A4152 A4153 A4159 A4189 A419 A420 A421 A422 47

48 Diagnosis Codes A4289 A429 A430 A431 A438 A439 A480 A483 A488 A4901 A492 A493 A498 A711 A719 A740 A800 A801 A802 A8030 A8039 A804 A809 A811 A812 A8181 A8189 A819 B0050 B0053 B0059 B0581 B081 B0820 B0821 B0822 B083 B09 B1001 B1009 B1081 B1082 B20 B250 B251 B252 B258 B259 B300 B301 B302 B303 B308 B309 B333 B334 B338 B471 B479 B950 B951 B952 B953 B954 B955 B9561 B957 B958 B960 B961 B963 B964 B965 B966 B967 B9681 B9682 B9689 B970 B9711 B9712 B9730 B9733 B9734 B9735 B9739 B977 E1010 E1011 E1021 E1022 E1029 E10311 E10319 E10321 E10329 E10331 E10339 E10341 E10349 E10351 E10359 E1036 E1039 E1040 E1041 E1042 E1043 E1044 E1049 E1051 E1052 E1059 E10610 E10618 E10620 E10621 E10622 E10628 E10630 E10638 E10641 E10649 E1065 E1069 E108 E109 E1101 E1121 E1122 E1129 E11311 E11319 E11321 E11329 E11331 E11339 E11341 E11349 E11351 E11359 E1136 E1139 E1140 E1141 E1142 E1143 E1144 E1149 E1151 E1152 E1159 E11610 E11620 E11621 E11622 E11628 E11630 E11638 E11641 E11649 E1165 E1169 E118 E119 E1301 E1310 E1311 E1321 E1322 E1329 E13311 E13319 E13321 E13329 E13331 E13339 E13341 E13349 E13351 E13359 E1336 E1339 E1340 E1341 E1342 E1343 E1344 E1349 E1351 E1352 E1359 E13610 E13641 E138 E139 F0150 F0151 F0280 F0281 F0390 F04 F05 F060 F061 F062 F0630 F0631 F0632 F0633 F0634 F064 F068 F070 F0781 F09 F1010 F10120 F10121 F10129 F1014 F10150 F10151 F10159 F10180 F10181 F10182 F10188 F1019 F1020 F1021 F10220 F10221 F10229 F10230 F10231 F10239 F1024 F10250 F10251 F10259 F1026 F1027 F10280 F10281 F10282 F10288 F1029 F10921 F10929 F10950 F10951 F10959 F1096 F1097 F10980 F10982 F1099 F1110 F11121 F1114 F11150 F11151 F11159 F11181 F11182 F11188 F1119 F1120 F1121 F11221 F11222 F1123 F1124 F11250 F11251 F11259 F11281 F11282 F11288 F1129 F11921 F11922 F1193 F1194 F11950 F11951 F11959 F11981 F11982 F11988 F1199 F1210 F12121 F12122 F12150 F12151 F12159 F12180 F12188 F1219 F1220 F1221 F12221 F12222 F12250 F12251 F12259 F12280 F12288 F1229 F1290 F12921 F12922 F12950 F12951 F12959 F12980 F12988 F

49 Diagnosis Codes F1310 F13120 F13150 F13151 F13159 F13180 F13181 F13182 F13188 F1320 F1321 F13230 F13232 F13239 F13250 F13251 F13259 F1326 F1327 F13280 F13281 F13282 F13288 F13950 F13951 F13959 F1396 F1397 F13980 F13981 F13982 F13988 F1410 F14121 F14122 F1414 F14150 F14151 F14159 F14180 F14181 F14182 F14188 F1419 F1420 F1421 F14221 F14222 F1423 F1424 F14250 F14251 F14259 F14280 F14281 F14282 F14288 F1429 F14921 F14922 F1494 F14950 F14951 F14959 F14980 F14981 F14982 F14988 F1499 F1510 F15121 F15122 F1514 F15150 F15151 F15159 F15180 F15181 F15182 F15188 F1519 F1520 F1521 F15221 F15222 F1523 F1524 F15250 F15251 F15259 F15280 F15281 F15282 F15288 F1529 F15920 F15921 F15922 F1593 F1594 F15950 F15951 F15959 F15980 F15981 F15982 F15988 F1599 F1610 F16121 F16122 F1614 F16150 F16151 F16159 F16180 F16183 F16188 F1619 F1620 F1621 F16221 F1624 F16250 F16251 F16259 F16280 F16283 F16288 F1629 F16921 F1694 F16950 F16951 F16959 F16980 F16983 F16988 F1699 F17200 F17201 F17203 F17208 F17209 F17210 F17218 F17220 F17228 F17290 F17298 F1810 F18121 F1814 F18150 F18151 F18159 F1817 F18180 F18188 F1819 F1820 F1821 F18221 F1824 F18250 F18251 F18259 F1827 F18280 F18288 F1829 F18921 F1894 F18950 F18951 F18959 F1897 F18980 F18988 F1899 F1910 F19121 F19122 F1914 F19150 F19151 F19159 F1916 F1917 F19180 F19181 F19182 F19188 F1919 F1920 F1921 F19221 F19222 F19230 F19232 F19239 F1924 F19250 F19251 F19259 F1926 F1927 F19280 F19281 F19282 F19288 F1929 F19921 F19922 F19930 F19932 F19939 F1994 F19950 F19951 F19959 F1996 F1997 F19980 F19981 F19982 F19988 F1999 F200 F201 F202 F205 F2081 F2089 F209 F21 F22 F23 F24 F250 F251 F258 F259 F28 F29 F3010 F3011 F3012 F3013 F302 F303 F304 F308 F310 F3110 F3111 F3112 F3113 F312 F3130 F3131 F3132 F314 F315 F3160 F3161 F3162 F3163 F3164 F3170 F3171 F3172 F3173 F3174 F3175 F3176 F3177 F3178 F3181 F3189 F319 F320 F321 F322 F323 F324 F325 F328 F329 F330 F331 F332 F333 F3340 F3341 F3342 F338 F339 F340 F341 F348 F349 F39 F4000 F4001 F4002 F4010 F4011 F40210 F40218 F40220 F40228 F40230 F40231 F40232 F40233 F40240 F40241 F40242 F

50 Diagnosis Codes F40248 F40290 F40291 F40298 F408 F409 F410 F411 F413 F418 F419 F42 F430 F4310 F4311 F4312 F4320 F4321 F4322 F4323 F4324 F4325 F4329 F438 F440 F441 F444 F446 F447 F4481 F4489 F449 F450 F451 F4520 F4521 F4522 F4529 F4541 F4542 F458 F459 F481 F488 F489 F5000 F5001 F5002 F502 F508 F509 F5101 F5102 F5103 F5104 F5109 F5111 F5112 F5119 F513 F514 F515 F518 F519 F520 F521 F5221 F5222 F5231 F5232 F524 F525 F526 F528 F529 F53 F551 F553 F59 F600 F601 F602 F603 F604 F605 F606 F607 F6081 F6089 F609 F630 F631 F632 F633 F6381 F6389 F639 F641 F642 F648 F650 F651 F652 F653 F654 F6551 F6552 F6581 F6589 F659 F66 F6810 F6811 F6812 F6813 F688 F800 F801 F802 F804 F8089 F809 F810 F812 F8181 F8189 F819 F82 F840 F843 F845 F848 F849 F88 F89 F900 F901 F902 F908 F909 F911 F912 F913 F918 F919 F930 F938 F939 F940 F941 F942 F948 F950 F951 F952 F958 F959 F980 F981 F9821 F9829 F983 F984 F985 F988 F989 F99 G44209 H9325 K9081 L081 L444 M60009 R37 R451 R457 R480 Z87890 Combination Diagnosis Codes (Must be submitted in pairs) E1010 E1065 E1051 E1065 E1136 E1165 E1011 E1065 E1069 E1065 E1139 E1165 E1021 E1065 E108 E1065 E1140 E1165 E10311 E1065 E1100 E1165 E1151 E1165 E10319 E1065 E1101 E1165 E1169 E1165 For other professional services, fitting services are included in the reimbursement for prosthetic eyeglasses or contact lenses Vision Services for Nonprosthetic Eyewear E1036 E1065 E1121 E1165 E118 E1165 E1039 E1065 E11311 E1165 F0390 F05 E1040 E1065 E11319 E1165 Definition: Nonprosthetic eyewear is medically necessary to correct defects in vision. Providers may refer to TAC for more information. 50

51 Limitations: Nonprosthetic eyeglasses or contact lenses may be reimbursed for clients of any age when there is no other option available to correct or ameliorate a visual defect. Prescribing and dispensing medically necessary eyeglasses or contact lenses are benefits of Texas Medicaid as follows: Nonprosthetic eyeglasses or contact lenses may be reimbursed once every 24 months. Additional services within the 24-month period may be considered when documentation in the client s medical record supports medical necessity that includes a diopter change of 0.5d or more in the sphere, cylinder, prism measurements, or axis changes. A new 24 month benefit period for eyewear begins with the placement of the new nonprosthetic eyewear. Replacement of nonprosthetic eyeglasses or contact lenses because of loss or destruction is a benefit of Texas Medicaid for clients who are birth through 20 years of age. If the eyeglasses or contact lenses are lost or destroyed, the provider must have the client sign the Vision Care Eyeglass Patient (Medicaid Client) Certification Form and the signed form must be maintained in the client s medical record. For clients who have had insertion of an intraocular lens (IOL), one pair of eyeglasses or contact lenses may be reimbursed. Additional eyeglasses or contact lenses may be considered when documentation in the client s medical record supports medical necessity that includes a diopter change of 0.5d or more in the sphere, cylinder, prism measurements, or axis changes. Note: Because the IOL is considered the prosthetic device, the eyeglasses or contact lenses, and any replacements, are considered nonprosthetic. Refer to: Subsection , Routine Vision Testing in this handbook for information about vision testing for the purposes of prescribing eyewear. The prescription for eyeglasses must be given to the client upon request. A provider may not withhold a prescription for eyeglasses from a client even if Medicaid reimbursement for the eye examination has not been received. To be considered by Texas Medicaid, the eyeglasses or contact lenses must be: Medically necessary. Prescribed by a doctor of medicine, optometry, or osteopathy. Prescribed to significantly improve vision or correct a medical condition. In compliance with eyeglass program specifications for frames and lenses as stated in TAC Rule , Specifications for Eyewear and Rule , Specifications for Eyewear Eyeglass Lenses and Frames The following eyeglass lens procedure codes may be billed with frame procedure codes V2020 and V2025 for reimbursement of a pair of eyeglasses: Procedure Codes Single Vision Lenses V2100 V2101 V2102 V2103 V2104 V2105 V2106 V2107 V2108 V2109 V2110 V2111 V2112 V2113 V2114 V2115 V2118 V2121 Bifocal Lenses V2200 V2201 V2202 V2203 V2204 V2205 V2206 V2207 V2208 V2209 V2210 V2211 V2212 V2213 V2214 V2215 V2218 V2219 V2220 V2221 Trifocal Lenses V2300 V2301 V2302 V2303 V2304 V2305 V2306 V2307 V2308 V2309 V2310 V2311 V2312 V2313 V2314 V2315 V2318 V2319 V2320 V

52 For the purpose of Texas Medicaid, high-powered lenses are lenses with a sphere greater than 7.00d or a cylinder greater than 4.00d. Providers must bill a quantity of two when billing for bilateral lenses with the same prescription. The following procedure codes may be reimbursed for add-on services: Add-On Procedure Codes V2410 V2430 V2700 V2710 V2715 V2718 V2730 V2755 V2770 V2780 V2784 Add-on procedure codes will not be reimbursed unless they are billed with the appropriate lens procedure code by the same provider for the same date of service. The fitting of eyeglasses (procedure codes 92340, 92341, 92342, and 92370) is considered part of the dispensing procedure and is not separately reimbursed. Polycarbonate Lens Procedure code V2784 for polycarbonate lens is considered an add-on procedure code. Polycarbonate lenses may be reimbursed for clients with one of the following medical or physical conditions that are a high risk for eye injuries due to eyewear breakage (this list is not all-inclusive): Cerebral palsy Multiple sclerosis Muscular dystrophy Epilepsy Autism Down syndrome Brain trauma Balance disorders Parkinson disease Seizure disorder Motor ataxia Marfan s syndrome Ocular prostheses Amblyopia In addition to the medical or physical conditions identified above, polycarbonate lenses also may be reimbursed when the client meets the following criteria: Lens power in at least one meridian of -5.25/+4.00 diopters or more and the eyeglasses are not functional in regular standard glass or plastic lens materials due to weight, thickness or aberration Monocular vision with functional vision in one eye Retinal detachment or risk for retinal detachment (e.g., lattice degeneration, history of retinal detachment in the family, posterior vitreous detachment) 52

53 Procedure code V2784 may be reimbursed when it is billed with one of the following diagnosis codes or combination diagnosis codes: Diagnosis Codes Single Diagnosis Codes (Submitted as stand-alone diagnosis codes) F840 F843 F845 F848 F849 F951 G20 G2111 G2119 G213 G214 G218 G3183 G3184 G35 G40001 G40009 G40019 G40101 G40109 G40111 G40119 G40201 G40209 G40211 G40219 G40301 G40309 G40311 G40401 G40409 G40411 G40419 G40501 G40509 G40801 G40802 G40803 G40804 G40813 G4089 G40901 G40909 G40911 G40919 G40A01 G40A09 G40A11 G40A19 G40B01 G40B09 G40B11 G40B19 G710 G7111 G7112 G7113 G7114 G7119 G712 G713 G718 G720 G722 G723 G7241 G7249 G7281 G7289 G729 G737 G800 G801 G802 G804 G808 G809 H33001 H33002 H33003 H33011 H33012 H33013 H33021 H33022 H33023 H33031 H33032 H33033 H33041 H33042 H33043 H33051 H33052 H33053 H33191 H33192 H33193 H3321 H3322 H3323 H33301 H33302 H33303 H33311 H33312 H33313 H33321 H33322 H33323 H33331 H33332 H33333 H3341 H3342 H3343 H338 H53001 H53002 H53003 H53011 H53012 H53013 H53021 H53022 H53023 H53031 H53032 H53033 H5441 H5442 H5451 H5452 H8101 H8102 H8103 H8109 H8110 H8111 H8112 H8113 H8120 H8121 H8122 H8123 H81311 H81312 H81313 H81319 H81391 H81392 H81393 H81399 H8301 H8302 H8303 H8309 H8311 H8312 H8313 H8319 H832X1 H832X2 H832X3 H832X9 P100 P101 P104 P108 P524 P526 P528 Q8740 Q87410 Q87418 Q8742 Q8743 Q900 Q901 Q902 Q909 S06890A S06890D S06890S S06891A S06891D S06891S S06892A S06892D S06892S S06893A S06893D S06893S S06894A S06894D S06894S S06895A S06895D S06895S S06896A S06896D S06896S S06899A S06899D S06899S S069X0A S069X0D S069X0S S069X1A S069X1D S069X1S S069X2A S069X2D S069X2S S069X3A S069X3D S069X3S S069X4A S069X4D S069X4S S069X5A S069X5D S069X5S S069X6A S069X6D S069X6S S069X9A S069X9D S069X9S T8521XA T8521XD T8521XS T8522XA T8522XD T8522XS T8529XA T8529XD T8529XS T85310A T85310D T85310S T85311A T85311D T85311S T85318A T85318D T85318S T85320A T85320D T85320S T85321A T85321D T85321S T85328A T85328D T85328S T85390A T85390D T85390S T85391A T85391D T85391S T85398A T85398D T85398S T8579XA T8579XD T8579XS Combination Diagnosis Codes (Must be submitted in pairs) S06890A S0190XA S06891A S0190XA S06892A S0190XA S06893A S0190XA S06894A S0190XA S06895A S0190XA S06896A S0190XA S06899A S0190XA 53

54 For lens power in at least one meridian of -5.25/+4.00 diopters or more, and the eyeglasses are not functional in regular standard glass or plastic lens material due to weight, thickness or aberration, providers must submit one of the following lens procedure codes: Procedure Codes V2101 V2102 V2105 V2106 V2107 V2108 V2109 V2110 V2111 V2112 V2113 V2114 V2201 V2202 V2205 V2206 V2207 V2208 V2209 V2210 V2211 V2212 V2213 V2214 V2301 V2302 V2306 V2307 V2308 V2309 V2310 V2311 V2312 V2313 V2314 For diagnoses not listed in the above table or for lens power other than those listed in this section, providers must submit documentation of medical necessity. If documentation is not submitted with the claim, the polycarbonate lenses will be denied. Undeliverable Eyeglasses The provider may be reimbursed for the lenses based on the services furnished and the materials used up to the time the provider learned that the eyeglasses were undeliverable due to any of the following: The client cancels an order for eyeglasses prior to their completion and delivery. The prescription changes prior to completion and delivery of the eyeglasses. The client dies prior to completion and delivery of the eyeglasses. Reimbursement will not be made for the frames Contact Lens and Corneal Bandage The following procedure codes may be reimbursed for prosthetic and nonprosthetic contact lenses: Procedure Codes V2500 V2501 V2502 V2510 V2511 V2512 V2513 V2520 V2521 V2522 V2523 V2530 V2531 V2599 The following procedure codes may be reimbursed for the fitting or modification of a contact lens: Procedure Codes Note: Procedure codes and must be submitted with modifier LT or RT and will be denied if it is billed with the same date of service as procedure codes and Corneal Bandage A soft corneal plano bandage lens may be medically necessary for eye protection to prevent blindness due to a disease process. Procedure codes and may be reimbursed for the fitting of the corneal bandage for treatment and management. Corneal bandage may be reimbursed once per eye, per day when it is billed by any provider. Modifier LT or RT must be included on the claim to identify the eye on which the service was performed. 54

55 Prior Authorization Requirements Nonprosthetic contact lenses and corneal plano bandage lenses must be prior authorized. The following documentation must be submitted with a request for nonprosthetic contact lenses and must be signed and dated by the prescribing physician or optometrist: Diagnosis causing the refractive error (such as keratoconus) Include the current and new prescriptions supporting a change of 0.5d or more in the sphere, cylinder, or prism measurements Indicate which eyes to be treated Specify the procedure codes requested Include a brief statement addressing the medical necessity for vision correction by contact lens(es) and specify why eyeglasses are inappropriate or contraindicated for this client For the soft corneal plano bandage lens (procedure code or 92072), nonprosthetic contact lenses for nonemergency placement require prior authorization that must be obtained before the lenses are dispensed. Documentation submitted with the request must include the information listed above. Nonprosthetic contact lenses for emergency placement do not require prior authorization. The emergency condition necessitating a corneal bandage must be documented on the claim. Additional nonprosthetic contact lenses may be considered more frequently than the limitations outlined in this handbook when documentation in the client s medical record supports medical necessity for a diopter change of 0.5d or more in the sphere, cylinder, prism measurements, or axis changes Dispensing Requirements Providers must be able to dispense standard size frames at no cost to the eligible client. The following criteria must be met for the dispensed frames: Providers must offer each client who is 20 years of age or younger a choice of six styles in three colors for each type of frame: metal, zylonite, or combination of metal and zylonite. Providers must offer each client who is 21 years of age or older a choice of three styles in three colors for each type of frame: metal, zylonite, or combination of metal and zylonite. When a client chooses eyeglass or contact lens options that are beyond program limitations, the client must acknowledge their choice and his or her liability for the cost difference by signing the Vision Care Eyeglass Patient (Medicaid Client) Certification Form. Dispensing of contact lenses include the fabrication, ordering, adjustment, dispensing, sale, and delivery to the client of the contact lenses prescribed by and dispensed in accordance with a prescription from a licensed physician or optometrist. Dispensing of eyeglasses includes the design, verification, fitting, adjustment, sale, and delivery to the client of (1) fabricated and finished spectacle lenses, (2) frames, or (3) other ophthalmic devices, prescribed by and dispensed in accordance with a prescription from a licensed physician or optometrist Repair The eyeglass supplier is required to perform minor repairs on request (without charge) on eyeglasses that they have dispensed regardless of the client s age. Minor repairs are those that cost $2 or less. The minor repairs are included in the reimbursement for the eyeglasses and are not reimbursed separately. For clients who are birth through 20 years of age, repairs that cost $2 or more may be reimbursed using procedure code V2799. The following criteria apply: The cost of repair supplies cannot exceed the cost of replacement eyeglasses. 55

56 All repair supplies must be new and at least equivalent to the original item. The provider must maintain in the client s medical record an itemized list of repairs and the replacement cost to determine whether criteria are met for repair. For clients who are 21 years of age and older, repair of nonprosthetic eyeglasses or contact lenses is not a benefit when the actual cost of materials exceeds $2. The provider must make the client s medical record available for review upon request Replacement Clients who are birth through 20 years of age may obtain replacement nonprosthetic eyeglasses if the first pair is lost or destroyed. There are no limitations on the number of replacements a client who is birth through 20 years of age may receive. If the eyewear is lost or destroyed, the provider must have the client sign the Vision Care Eyeglass Patient (Medicaid Client) Certification Form. Claims for replacement lenses must be submitted with the RB modifier to ensure accurate processing. Prior authorization is not required for the replacement of nonprosthetic eyeglasses. Replacement of eyeglasses or contact lenses is also allowed with a change in axis. A new prescription must have at least one of the following changes: A change of 0.50 diopters or more in any corresponding meridian. A cylinder axis change of at least 20 degree for a cylinder power of diopters. A cylinder axis change of at least 15 degree for a cylinder power of diopters. A cylinder axis change of at least 10 degree for a cylinder power of diopters. A cylinder axis change of at least 5 degree for a cylinder power of 2.00 diopters or greater. Note: Replacement glasses will not be reimbursed for a cylinder power of diopters with a change in axis. Prior authorization is required for replacement of non-prosthetic contact lenses. If the client is diagnosed with aphakia, procedure code may be reimbursed for the replacement of a contact lens. Procedure code is limited to aphakia Medicare Coverage for Nonprosthetic Eyewear Eye examinations for the purpose of prescribing, fitting, or changing eyeglasses or contact lenses because of refractive errors are not a benefit of Medicare. These services must be filed directly to Texas Medicaid when performed for a Medicaid Qualified Medicare Beneficiary (MQMB) 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 an MQMB client diagnosed with aphakia or disease or injury to the eye, the following procedures must be followed: Procedure code must be used to bill Texas 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 (procedure code 92002, 92004, 92012, or 92014) is covered by Medicare and must be billed to Medicare first. Medicare forwards this portion of the examination automatically to TMHP for deductible and coinsurance payment consideration according to current guidelines. 56

57 Refer to: Subsection 2.7, Medicare Crossover Claim Reimbursement in Section 2, Medicaid Feefor-Service Reimbursement (Vol. 1, General Information) for more information about current coinsurance and deductible payment guidelines. Important: Providers performing eye exams for refractive errors on Medicaid Qualified Medicare Beneficiary (MQMB) clients must bill TMHP. Do not send the refraction (procedure code 92015) to Medicare first. Texas 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 Texas Medicaid for payment. 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 considers the IOL the prosthetic device. Texas Medicaid providers must bill Medicare for the conventional (nonprosthetic) eyewear provided following an IOL insertion and bill Texas Medicaid for any replacements of the conventional (nonprosthetic) eyewear using the procedure codes in subsection 4.3.6, Vision Services for Nonprosthetic Eyewear in this handbook Vision Services for Prosthetic Eyewear Definition: Prosthetic eyeglasses or contact lenses are lenses that replace the eye s organic lens when it is absent due to congenital or acquired aphakia. Aphakia may be the result of a congenital abnormality or defect or an acquired condition as a result of trauma or cataract removal. Limitations: Prosthetic eyeglasses or contact lenses may be provided based on medical necessity. Eye examinations and prosthetic eyewear may be reimbursed as follows: Eye examinations for aphakia (including congenital aphakia) and disease or injury to the eye may be reimbursed as often as is medically necessary. One pair of permanent prosthetic eyeglasses or contact lenses is a benefit during a client s lifetime. Replacement of prosthetic eyeglasses or contact lenses may be reimbursed for clients of any age due to loss or destruction of the eyewear or due to a significant change in visual acuity with a diopter change of 0.5d or more in the sphere, cylinder, prism measurements, or axis changes. The provider must maintain in the client s medical record documentation that supports the medical necessity for the replacement eyeglasses or contact lenses. Prosthetic eyeglasses or contact lenses may be reimbursed when billed with modifier VP and one of the following aphakia. Prosthetic eyeglasses or contact lenses are limited to one of the diagnosis codes listed in the table below: Diagnosis Codes H2701 H2702 H2703 H27111 H27112 H27113 H27121 H27122 H27123 H27131 H27132 H27133 Q123 Z961 Refer to: Subsection 4.3.6, Vision Services for Nonprosthetic Eyewear in this handbook for the eyeglass lens, frame, and contact lens procedure codes and dispensing requirements that apply to prosthetic and nonprosthetic eyewear. Prior authorization is not required for prosthetic eyeglasses or contact lenses. The date of cataract surgery is not required on the claim for permanent prosthetic eyeglasses Temporary Eyeglasses or Contact Lenses Temporary prosthetic eyeglasses or contact lenses after cataract surgery may be reimbursed when it is billed with the appropriate lens and frame procedure codes and diagnosis code Z

58 Temporary prosthetic eyeglasses may be reimbursed for up to 4 months after surgery until the client is ready for permanent prosthetic lenses. The date of surgery is used to determine the convalescence period for temporary prosthetic eyeglasses. Temporary lenses will be denied if they are dispensed more than 4 months after the date of surgery. Temporary prosthetic lenses may be reimbursed as often as is medically necessary during the postsurgical convalescence period Contact Lens Fitting and Modification The following procedure codes may be reimbursed for prosthetic and nonprosthetic contact lenses fitting: Procedure Codes Fitting services are included in the reimbursement for prosthetic and nonprosthetic eyeglasses or contact lenses. Prior authorization for a prosthetic contact lens is not required Repair The eyeglass supplier is required to perform minor repairs on request (without charge) on eyeglasses that they have dispensed regardless of the client s age. Minor repairs are those that cost $2 or less. The minor repairs are included in the reimbursement for the eyeglasses and are not reimbursed separately. Repairs that cost $2 or more may be reimbursed using procedure code V2799. The following criteria apply: The cost of repair supplies cannot exceed the cost of replacement eyeglasses. All repair supplies must be new and at least equivalent to the original item. The provider must maintain in the client s medical record an itemized list of repairs and the replacement cost to determine whether criteria are met for repair. The provider must make the client s medical record available for review upon request Replacement Replacement prosthetic eyeglasses or contact lenses may be reimbursed as often as is medically necessary if the replacement is due to loss, destruction, or a significant change in visual acuity. Replacement of eyeglasses or contact lenses is also allowed with a change in axis. A new prescription must have at least one of the following changes: A change of 0.50 diopters or more in any corresponding meridian. A cylinder axis change of at least 20 degree for a cylinder power of diopters. A cylinder axis change of at least 15 degree for a cylinder power of diopters. A cylinder axis change of at least 10 degree for a cylinder power of diopters. A cylinder axis change of at least 5 degree for a cylinder power of 2.00 diopters or greater. Note: Replacement glasses will not be reimbursed for a cylinder power of diopters with a change in axis. The appropriate eyeglass and frame or contact lens procedure codes must be billed with modifier RB to indicate replacement. 58

59 Refer to: Subsection 4.3.6, Vision Services for Nonprosthetic Eyewear in this handbook for the eyeglass lens, frame, and contact lens procedure codes and dispensing requirements that apply to prosthetic and nonprosthetic eyewear. Procedure code for the replacement of a contact lens may be reimbursed when it is billed with a diagnosis of aphakia: Diagnosis Codes H2701 H2702 H2703 H27111 H27112 H27113 H27121 H27122 H27123 H27131 H27132 H27133 Q123 Z Intraocular Lens (IOL) and Additional Eyewear Intraocular lenses are benefits of Texas Medicaid. If conventional eyewear is medically necessary in addition to the IOL, the IOL is considered the prosthetic device, and the eyewear and any replacements are considered nonprosthetic. Refer to: Subsection , Intraocular Lens (IOL) in Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook (Vol. 2, Provider Handbooks) for more information about IOL benefits. Subsection 4.3.6, Vision Services for Nonprosthetic Eyewear in this handbook for more information about nonprosthetic eyewear Artificial Eyes For clients who are birth through 20 years of age, artificial eyes may be considered under CCP Ultraviolet (U-V) Protection Procedure code V2755 may be reimbursed for U-V protection when billed with one of the following diagnosis codes: Diagnosis Codes H2701 H2702 H2703 H27111 H27112 H27113 H27121 H27122 H27123 H27131 H27132 H27133 Q123 Z961 UV lens procedure code V2755 will be denied when billed with the same date of service by the same provider as polycarbonate lens procedure code V2784. UV and polycarbonate lens procedure codes are subject to CMS NCCI relationships. Refer to: The CMS NCCI web page for the published correct coding guidelines and specific applicable code combinations Surgical Vision Services Refer to: Subsection , Fluocinolone Acetonide (Retisert) in Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook (Vol. 2, Provider Handbooks) for more information about fluocinolone acetonide benefits. Subsection , Ophthalmology in Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook (Vol. 2, Provider Handbooks) for more information about surgical vision services. 4.4 Documentation Requirements All services require documentation to support the medical necessity of the service rendered, including vision services. Vision services are subject to retrospective review and recoupment if documentation does not support the service billed. 59

60 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. When a client chooses an eyeglasses or contact lens option beyond the program limitations, or nonprosthetic eyeglasses or contact lenses are replaced because of loss or destruction the client must acknowledge their choice and liability for the cost difference by signing the Vision Care Eyeglass Patient (Medicaid Client) Certification Form and retain it in the provider s records. The current and previous prescriptions must be documented in the client s medical record. The provider must make the client s medical record available for review upon request by the following: HHSC Office of the Attorney General TMHP 4.5 Claims Filing and Reimbursement Claims Filing Vision care service claims must be submitted to TMHP in an approved electronic format or on a CMS paper claim form. Providers may purchase CMS-1500 paper claim forms from the vendor of their choice. TMHP does not supply the forms. When completing a CMS-1500 paper 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 to show an axis change or a diopter change of.5 or more, enter the new prescription in Block 24D, line 5, and the old prescription in Block 24D, line 6 of the CMS-1500 paper claim form. Claims for eye examination services require a diagnosis. 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. When the eye exam limitation is exceeded for clients who are 20 years of age and younger, identify one of the following situations in Block 19 of the CMS-1500 paper claim form: A school nurse, teacher, or parent requests the eye examination. The eye examination is medically necessary Reimbursement Professional services by an optometrist for contact lenses and prosthetic eyewear are reimbursed in accordance with 1 TAC, , , and FQHCs are paid an all-inclusive 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 OFL or the applicable fee schedule on the TMHP website at Refer to: Subsection 2.2, Fee-for-Service Reimbursement Methodology in Section 2, Texas Medicaid Fee-for-Service Reimbursement (Vol. 1, General Information) for more information about reimbursement. Vision Services on the TMHP website at for a claim form example. The nonsurgical vision procedure codes included in this handbook may be subject to the CMS NCCI relationships. 60

61 Refer to: The CMS website at for more information about NCCI relationships. Texas Medicaid implemented mandated rate reductions for certain services. The OFL and static fee schedules include a column titled Adjusted Fee to display the individual fees with all mandated percentage reductions applied. Additional information about rate changes is available on the TMHP website at NCCI and MUE Guidelines The HCPCS and CPT codes included in the Texas Medicaid Provider Procedures Manual are subject to NCCI relationships, which supersede any exceptions to NCCI code relationships that may be noted in the manuals. Providers should refer to the CMS NCCI web page for correct coding guidelines and specific applicable code combinations. In instances when Texas Medicaid limitations are more restrictive than NCCI MUE guidance, Texas Medicaid limitations prevail. If applicable and consistent with CMS billing guidelines, procedure codes must be billed with modifier LT (left side) or RT (right side) to identify the eye on which the service was performed. 5 Claims Resources Refer to the following sections and forms when filing claims: Resource Appendix D: Acronym Dictionary Automated Inquiry System (AIS) CMS-1500 Paper Claim Filing Instructions Appendix A: State, Federal, and TMHP Contact Information Section 3: TMHP Electronic Data Interchange (EDI) TMHP Electronic Claims Submission Location Appendix D (Vol. 1, General Information) Appendix A: State, Federal, and TMHP Contact Information (Vol. 1, General Information) Subsection 6.5 (Vol. 1, General Information) Appendix A (Vol. 1, General Information) Section 3 (Vol. 1, General Information) Subsection 6.2 (Vol. 1, General Information) 6 Contact TMHP The TMHP Contact Center at is available Monday through Friday from 7 a.m. to 7 p.m., Central Time. 7 Forms The following linked forms can also be found on the Forms page of the Provider section of the TMHP website at Forms Hearing Evaluation, Fitting, and Dispensing Report (Form 3503) Physician s Examination Report Vision Care Eyeglass Patient (Medicaid Client) Certification Form Vision Care Eyeglass Patient (Medicaid Client) Certification Form (Spanish) 61

62 8 Claim Form Examples The following linked claim form examples can also be found on the Claim Form Examples page of the Provider section of the TMHP website at Claim Form Examples Hearing Aid Assessments Vision Services 62