TMPPM 2007 >45.4.3 Medicare/Medicaid

45.4.3 Medicare/Medicaid

Eye examinations for the purpose of prescribing, fitting, or changing eyeglasses/contact lenses because of refractive errors are not a benefit of Medicare. These services must be filed directly to Medicaid when performed for a Medicare/Medicaid client. Medicare coverage is limited to eye examinations for treatment of eye disease or injury and for a diagnosis of aphakia. When performing an eye examination with refraction for a Medicare/Medicaid client diagnosed with aphakia or disease or injury to the eye, the following procedures must be followed:

•Procedure code 1-92015 must be used to bill Medicaid for the refractive portion of the examination and is payable with a diagnosis of aphakia or ocular disease only.

•The medical portion of the eye examination (1-92002, 1-92004, 1-92012, 1-92014) is covered by Medicare and must be billed to Medicare first. Medicare forwards this portion of the examination automatically to TMHP for payment of coinsurance and/or deductible.

Important: Providers performing eye exams for refractive errors on STAR+PLUS Medicaid Eligibility Verification (Medicaid Qualified Medicare Beneficiary [MQMB]) must bill TMHP, not the STAR+PLUS health plan.
Do not send the refraction (1-92015) to Medicare first. Medicaid will not waive the 95-day filing deadline if the claim is billed to Medicare in error, nor will Medicare transfer the refraction to Medicaid for payment.

Medicare allows payment of one pair of conventional eyewear (contact lens or glasses) for clients who have had cataract surgery with insertion of an intraocular lens (IOL) (Medicare considers the IOL the prosthetic device). Medicaid providers must bill Medicare for the conventional (nonprosthetic) eyewear provided following an IOL insertion and bill Medicaid for any replacements of the conventional (nonprosthetic) eyewear using the Y codes in the "Nonprosthetic Eyeglasses and Contacts" tables beginning on page 45-10.