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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 : 4.3.7 Vision Services for Prosthetic Eyewear

4.3.7
Prosthetic eyeglasses or contact lenses are lenses that replace the eye’s organic lens when it is absent due to congenital or acquired aphakia. Aphakia may be the result of a congenital abnormality or defect or an acquired condition as a result of trauma or cataract removal without intraocular lens (IOL) insertion.
Prosthetic eyeglasses or contact lenses may be provided based on medical necessity. Eye examinations and prosthetic eyewear may be reimbursed as follows:
Replacement of prosthetic eyeglasses or contact lenses may be reimbursed for clients of any age due to loss or destruction of the eyewear or due to a significant change in visual acuity with a diopter change of 0.5d or more in the sphere, cylinder, prism measurements, or axis changes. The provider must maintain in the client’s medical record documentation that supports the medical necessity for the replacement eyeglasses or contact lenses.
Prosthetic contact lenses may be provided, with prior authorization, for clients of any age with congenital or acquired aphakia.
Note:
Providers must use modifier VP with a diagnosis code of aphakia when billing for prosthetic eyeglasses or contact lenses.
Refer to:
Subsection 4.3.6, “Nonprosthetic Eyeglasses or Contact Lenses” in this handbook for the eyeglass lens, frame, and contact lens procedure codes and dispensing requirements that apply to prosthetic and nonprosthetic eyewear.
The date of cataract surgery is not required on the claim for conventional eyeglasses or contact lenses after surgery, or prosthetic eyeglasses or contact lenses after cataract surgery without IOL insertion.

Texas Medicaid & Healthcare Partnership
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