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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 : 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 76510, 76511, 76512, 76513, 76516, and 76519 are limited to two services per calendar year by any provider.
Procedure code 76999 requires prior authorization.
Procedure code 76514 may be reimbursed once per lifetime or as medically necessary as indicated when billed with one of the diagnosis codes in the following table:
Procedure code 76999 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 76514 and 76516) are limited to one service, per day, by any provider. Procedure codes 92002, 92004, 92012, 92014, and 92015 will not be reimbursed for routine exams.
Procedure code 76519 may be reimbursed as follows:
The professional interpretation component may be reimbursed when procedure code 76519 is billed with modifier LT or RT to identify the eye on which the service was performed.
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 76506.
Refer to:
The CMS NCCI web page for the published correct coding guidelines and specific applicable code combinations.
Prior Authorization Requirements
Procedure code 76999 requires prior authorization. The provider must submit the following documentation with the request:

Texas Medicaid & Healthcare Partnership
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