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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 : 4.3.6 Nonprosthetic Eyeglasses or Contact Lenses : 4.3.6.1 Eyeglass Lenses and Frames

4.3.6.1
The following eyeglass lens procedure codes may be billed with frame procedure codes V2020 and V2025 for reimbursement of a pair of eyeglasses:
 
For the purpose of Texas Medicaid, high-powered lenses are lenses with a sphere greater than 7.00d or a cylinder greater than 4.00d.
Providers must bill a quantity of two when billing for bilateral lenses with the same prescription.
The following procedure codes may be reimbursed for add-on services:
 
Add-on procedure codes will not be reimbursed unless they are billed with the appropriate lens procedure code by the same provider for the same date of service.
The fitting of eyeglasses (procedure codes 92340, 92341, 92342, and 92370) is considered part of the dispensing procedure and is not separately reimbursed.
Polycarbonate Lens
Polycarbonate lenses (procedure code V2784) may be reimbursed for clients with a medical or physical condition such as, but not limited to the following:
In addition to the medical or physical conditions identified above, polycarbonate lenses also may be reimbursed when the client meets the following criteria:
Lens power in at least one meridian of -5.25/+4.00 diopters or more and the eyeglasses are not functional in regular standard glass or plastic lens materials due to weight, thickness or aberration
Procedure code V2784 may be reimbursed when it is billed with one of the following diagnosis codes:
 
Polycarbonate lens claims must include a lens procedure code with lens power in at least one meridian of -5.25/+4.00 diopters or more, and the eyeglasses are not functional in regular standard glass or plastic lens material due to weight, thickness or aberration.
For diagnoses not listed in the above table or for lens power other than those listed in this section, providers must submit documentation of medical necessity. If documentation is not submitted with the claim, the polycarbonate lenses will be denied.
Undeliverable Eyeglasses
The provider may be reimbursed for the lenses based on the services furnished and the materials used up to the time the provider learned that the eyeglasses were undeliverable due to any of the following:
Reimbursement will not be made for the frames.

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