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December 2016 Texas Medicaid Provider Procedures Manual

Vision and HearingServices Handbook : 4 Vision Care Professionals : 4.3 Services, Benefits, Limitations, and Prior Authorization : 4.3.5 Vision Testing : 4.3.5.2 Medically Necessary Eye Examinations

4.3.5.2
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 92015 will not be reimbursed for routine exams.
Documentation in the client’s medical record must support the medical necessity of the service performed.
Procedure codes 92002, 92004, 92012, 92014, and 92015 may be reimbursed as often as is medically necessary to ophthalmologist or optometrist providers for medically necessary eye examinations without refraction.
Procedure code 92015 may be reimbursed to ophthalmologist or optometrist providers for refraction in addition to the eye examination procedure code 92002, 92004, 92012, or 92014. 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 S0621.

Texas Medicaid & Healthcare Partnership
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