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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 : 4.3.5.10 Ophthalmoscopy and Extended Ophthalmoscopy

4.3.5.10
Ophthalmoscopy and extended ophthalmoscopy may be reimbursed using the following procedure codes:
 
Ophthalmoscopy and fluorescein angioscopy or angiography (procedure codes 92225, 92226, 92230, and 92235) and indocyanine-green angiography (procedure code 92240) 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 92225, 92226, 92230, 92230, 92235, and 92240 are limited to one service per eye per day and two services per eye per calendar year when billed by any provider.
Procedure codes 92225, 92226, 92230, 92235, and 92240 must be billed with modifier LT or RT to identify the eye on which the service was performed.
Procedure codes 92250 and 92260 are limited to one service per day and two services per calender year by any provider.
Ophthalmoscopy, angioscopy, and angiography procedure codes are subject to CMS NCCI relationships.
Fundus photography (procedure code 92250) is considered medically necessary when a clinical condition exists that is subject to change in extent, appearance or size and where such change would directly affect the management of client care. These conditions include, but are not limited to the following:
Note:
Fundus photography performed for a routine screen of a normal eye, in the absence of a clinical condition, that is subject to change in extent, appearance or size is not a benefit of Texas Medicaid.

Texas Medicaid & Healthcare Partnership
CPT only copyright 2014 American Medical Association. All rights reserved.