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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 : Medicare Coverage for Nonprosthetic Eyewear
Eye examinations for the purpose of prescribing, fitting, or changing eyeglasses or contact lenses because of refractive errors are not a benefit of Medicare. These services must be filed directly to Texas Medicaid when performed for a Medicaid Qualified Medicare Beneficiary (MQMB) 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 an MQMB client diagnosed with aphakia or disease or injury to the eye, the following procedures must be followed:
Procedure code 92015 must be used to bill Texas 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 (procedure code 92002, 92004, 92012, or 92014) is covered by Medicare and must be billed to Medicare first. Medicare forwards this portion of the examination automatically to TMHP for deductible and coinsurance payment consideration according to current guidelines.
Refer to:
Subsection 2.7, “Medicare Crossover Claim Reimbursement” in Section 2, “Medicaid Fee-for-Service Reimbursement” (Vol. 1, General Information) for more information about current coinsurance and deductible payment guidelines.
Providers performing eye exams for refractive errors on Medicaid Qualified Medicare Beneficiary (MQMB) clients must bill TMHP. Do not send the refraction (procedure code 92015) to Medicare first. Texas 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 Texas 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 IOL. Medicare considers the IOL the prosthetic device. Texas Medicaid providers must bill Medicare for the conventional (nonprosthetic) eyewear provided following an IOL insertion and bill Texas Medicaid for any replacements of the conventional (nonprosthetic) eyewear using the procedure codes in subsection 4.3.6, “Nonprosthetic Eyeglasses or Contact Lenses” in this handbook.

Texas Medicaid & Healthcare Partnership
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