|
45.4.2 Eye Examinations for the Purpose of Prescribing Eyewear
Refer to the Eye Exam column of the client's current Medicaid Identification Form (Form H3087) to determine if the client is eligible for an eye examination. Clients are eligible for new eyewear whenever there is a diopter change of 0.5 or more (old and new prescription must appear on the claim).
Clients 20 years of age and younger are eligible for one examination with refraction for the purpose of obtaining eyewear during each state fiscal year (SFY) (September 1 to August 31, vision care annual periodicity schedule).
The eye exam limitation can be exceeded for clients younger than 21 years of age, but only in the following situations:
• A school nurse, teacher, or parent requests the eye examination (identify this information in Block 9 of the CMS-1500 claim form) if medically necessary.
•Medically necessary (identify this information in Block 19 of the CMS-1500 claim form).
Clients 21 years of age and older are eligible for one examination with refraction for the purpose of obtaining eyewear every 24 months.
A new patient eye examination will be limited to one every 24 months, per client, per provider. A new patient eye examination in any place of service (POS) will be denied if the history shows that the same provider has furnished a medical service (type of service [TOS] 1), a surgical service (TOS 2), or a consult (TOS 3) within two years. Services billed as new patient eye exams, procedure codes 1-92002 or 1-92004, in excess of this limitation will be denied.
Eye examinations for aphakia and disease or injury to the eye are not subject to any of the limitations listed above and are payable even if the Medicaid Identification Form (Form H3087) does not have a check mark (3) under the Eye Exam column.
Vision care services performed in SNF or ICF-MR must be ordered by the attending physician. Providers must document the physician's name and address or provider identifier in Block 17 of the CMS-1500 claim form. Claims submitted without this information are listed on the R&S as incomplete and must be corrected and resubmitted for consideration of payment. Electronic claims of this nature will be rejected. Attending physician information for electronic claims must be noted in the appropriate field of an approved electronic claims format.
If an office evaluation and management service or consultation is billed in addition to the eye exam, the evaluation and management service or consultation will be denied as part of the eye exam.
The following services are considered part of the office visit/eye examination reimbursement when performed on the same day:
Note: Procedure code 1-92015 may be considered separately for reimbursement if it is used to bill the Texas Medicaid Program for the refractive portion of an examination of clients who are eligible for both Medicare and Medicaid.
The following services may be billed in addition to an office visit/eye examination:
Orthoptic and/or pleoptics training is considered part of the office visit, and is not separately payable.
Office visits/eye examinations will be denied if billed with any of the following ophthalmology services on the same day:
In accordance with the Omnibus Budget Reconciliation Act (OBRA) of 1986, Section 9336, an optometrist 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 by an optometrist are not limited to procedure codes 1-S0620 and 1-S0621.
The following procedure codes are payable to optometrists when accompanied by an appropriate diagnosis:
Evaluation and management services and consultation codes (Table A) are payable to optometrists, when indicated, for the diagnoses in Table B.
Table A: Evaluation and Management Services and Consultation Procedure Codes.
Table B: Diagnosis Limitations
Procedure code 1-S0620 or 1-S0621 is payable with a diagnosis of refractive error only. Procedure code 1-92015 is not payable with a diagnosis of refractive error.
The following sonography procedures are payable to an optometrist when accompanied by an appropriate diagnosis:
If an office evaluation and management service is billed in addition to the eye examination, the evaluation and management service will be denied as part of the eye exam.
If a consultation is billed in addition to the eye exam, it will be denied as part of the eye exam.
Procedure code 1-99173 will deny as part of another procedure/service billed on the same day (e.g., Texas Health Steps [THSteps] visit or evaluation and management service).
|
