Vision and Hearing
Services Handbook

 

1 General Information

The information in this handbook is intended for optometrists (doctors of optometry), ophthalmolo­gists, and opticians who render services related to the eye and vision and for hearing aid professionals (fitters and dispensers, physicians, and audiologists) who provide hearing evaluations or fitting and dispensing services. The handbook provides information about Texas Medicaid’s benefits, policies, and procedures applicable to these providers.

Important:All providers are required to read and comply with subsection 4.1, “Enrollment” in this handbook. In addition to required compliance with all requirements specific to Texas Medicaid, it is a violation of Texas Medicaid rules when a provider fails to provide healthcare services or items to Medicaid clients in accordance with accepted medical community standards and standards that govern occupations, as explained in Title 1 Texas Adminis­trative Code (TAC) §371.1659. Accordingly, in addition to being subject to sanctions for failure to comply with the requirements that are specific to Texas Medicaid, providers can also be subject to Texas Medicaid sanctions for failure, at all times, to deliver healthcare items and services to Medicaid clients in full accordance with all applicable licensure and certifi­cation requirements including, without limitation, those related to documentation and record maintenance.

Refer to:  “Section 1: Provider Enrollment and Responsibilities” (Vol. 1, General Information).

This handbook contains information about Texas Medicaid fee-for-service benefits. For information about managed care benefits, refer to the Medicaid Managed Care Handbook (Vol. 2, Provider Handbooks).

Managed care carve-out services are administered as fee-for-service benefits. A list of all carve-out services is available in section 9, “Carve-Out Services” in the Medicaid Managed Care Handbook (Vol. 2, Provider Handbooks).

1.1Payment Window Reimbursement Guidelines for Services Preceding an Inpatient Admission

According to the three-day and one-day payment window reimbursement guidelines, most professional and outpatient diagnostic and nondiagnostic services that are rendered within the designated timeframe of an inpatient hospital stay and are related to the inpatient hospital admission will not be reimbursed separately from the inpatient hospital stay if the services are rendered by the hospital or an entity that is wholly owned or operated by the hospital.

These reimbursement guidelines do not apply in the following circumstances:

The professional services are rendered in the inpatient hospital setting.

The hospital and the physician office or other entity are both owned by a third party, such as a health system.

The hospital is not the sole or 100-percent owner of the entity.

Refer to:  Subsection 3.7.3.8, “Payment Window Reimbursement Guidelines” in the Inpatient and Outpatient Hospital Services Handbook (Vol. 2, Provider Handbooks) for additional infor­mation about the payment window reimbursement guidelines.

2 Nonimplantable Hearing Aid Devices and Related Services

2.1Enrollment

To enroll in Texas Medicaid, hearing aid professionals (physicians, audiologists, and hearing aid fitters and dispensers) who provide hearing evaluations or fitting and dispensing services must be licensed by the licensing board of their profession to practice in the state where the service is performed. Hearing aid providers are eligible to enroll as individuals and facilities. Audiologists are eligible to enroll as individuals and groups. Audiologists may enroll as both audiologists and as hearing aid fitters and dispensers by completing an enrollment application for each type of provider (i.e., select “Audiologist” on one application and “Hearing Aid” on the other application).

Providers cannot be enrolled if their license is due to expire within 30 days. A current license must be submitted.

2.1.1School Districts, State Agencies, and Inpatient Facilities

To be reimbursed for audiology and audiometry evaluation and diagnostic services for suspected and confirmed hearing loss (other than audiology evaluation and therapy services reimbursed to School Health and Related Services [SHARS] providers), audiologists employed by or contracted with school districts, state agencies, and inpatient hospitals must enroll as individual practitioners or group practi­tioners by choosing “Audiologist” on the enrollment application.

To be reimbursed for hearing aid devices and accessories, and fitting and dispensing visits and revisits, audiologists and hearing aid fitters and dispensers employed by or contracted with school districts, state agencies, and inpatient hospitals must enroll as individual practitioners or facilities by choosing “Hearing Aid” on the enrollment application.

Appropriately-licensed providers who want to provide both audiology services and hearing aid fitting and dispensing services must complete applications for audiologist and for hearing aid fitter and dispenser for each program for which they want to enroll.

Note:A SHARS Texas Provider Identifier (TPI) cannot be used to bill for these services.

2.2Services, Benefits, Limitations, and Prior Authorization

The Texas Medicaid hearing services benefit includes those services that are medically necessary for clients of any age who have suspected or identified hearing loss that can be improved or ameliorated using a hearing aid device. Such services may be reimbursed to audiologists or hearing aid fitters and dispensers.

Note:Hearing-related services that are medically necessary because of a medical condition that cannot be improved or ameliorated using a nonimplantable hearing aid device are not considered part of the Texas Medicaid hearing services benefit. Providers may refer to the other Texas Medicaid Provider Procedures Manual Handbooks for benefit and limitation information about other hearing-related services.

Texas Medicaid clients of any age are eligible to receive medically necessary hearing aid devices and services through the hearing services benefit outlined in the following sections. The Texas Medicaid hearing services benefit includes a broad range of hearing services for clients of all ages and reimburses providers who are appropriately enrolled with Texas Medicaid in accordance with their licensure and scope of practice. Prior authorization is not necessary for benefits within program limitations unless specifically addressed in the sections below.

The following hearing services are benefits of Texas Medicaid to appropriately-enrolled audiologists, hearing aid fitters and dispensers, and physicians according to their licensure, scope of practice, and enrollment as indicated:

Audiologists and physicians may be reimbursed for audiology and audiometry evaluation and diagnostic services for suspected and confirmed hearing loss.

Hearing aid fitters and dispensers may be reimbursed for hearing aid devices and accessories and fitting and dispensing visits and revisits.

Physicians may be reimbursed for physician otology and otorhinolaryngology (ENT) services.

Texas Medicaid clients whose jobs are contingent on their possessing a hearing aid or who appear to have vocational potential and who need a hearing aid may be referred to the Texas Department of Assistive and Rehabilitative Services (DARS) for hearing aids.

2.2.1Limitations and Required Forms

All services provided to Texas Medicaid clients must be medically necessary. Unless otherwise specified, services may be reimbursed without prior authorization within the set limitations. In addition to services that always require prior authorization, providers may request prior authorization for medically necessary services that exceed benefit limitations.

Required forms, which are indicated in the specific sections below, are not required to be submitted with the claim, but the forms must be completed and maintained in the client’s medical record and made available upon request by the Texas Health and Human Services Commission (HHSC) or the Texas Medicaid & Healthcare Partnership (TMHP) for retrospective review.

2.2.2Hearing Screenings

Hearing screening provided due to client concern, or at the provider’s discretion, is a benefit for clients of any age when the client is referred by a Medicaid-enrolled physician, and the screening is provided by a Medicaid-enrolled provider licensed to perform these services.

Routine newborn hearing screenings and Texas Health Steps (THSteps) medical checkup hearing screenings are benefits for Texas Medicaid clients, and are included in the reimbursement for the routine service or visit.

2.2.2.1Routine Hearing Screenings

Routine hearing screenings that are required as part of the newborn hospital stay and as part of a THSteps medical checkup are included in the Texas Medicaid hearing services benefit. These routine screenings are not reimbursed to audiologists, hearing aid fitters and dispensers, or physicians.

Newborn Hearing Screen

The newborn hearing screening is included in the reimbursement to the hospital for the newborn hospital stay and is not reimbursed separately. A newborn hearing screening must be offered to each newborn by the facility where the birth occurs, through a program mandated by the Texas State Legis­lature and certified by the Texas Department of State Health Services (DSHS). The screening is covered as part of the newborn delivery. An infant born outside a birthing facility and not admitted to a birthing facility shall be referred to a facility that provides newborn hearing screening. If a facility is not required by legislative mandate to perform newborn hearing screening, a referral must be made to a facility that offers the screening.

Refer to:  Subsection 5.3.9, “Newborn Examination” in the Children’s Services Handbook (Vol. 2, Provider Handbooks) for more information about the newborn hearing screening.

THSteps Medical Checkup Hearing Screen

Hearing screening is a required component of the THSteps medical checkup, and a standardized audio­metric hearing screening is required at specific ages according to the periodicity schedule.

Refer to:  The THSteps Medical Checkups Periodicity Schedule including the footnotes, which is available on the DSHS website at www.dshs.state.tx.us/thsteps/providers.shtm, for coverage criteria when performed as part of a THSteps medical checkup.

Subsection 5.3.11.2.3, “Hearing Screening” in the Children’s Services Handbook (Vol. 2, Provider Handbooks) for more information on THSteps checkup hearing screening.

2.2.2.2Additional Hearing Screenings

A hearing screening requested outside of a routine newborn or THSteps medical checkup may be reimbursed as medically necessary without prior authorization using procedure code 92551.

Further diagnostic testing may also be reimbursed using the appropriate procedure code as indicated in subsection 2.2.3, “Audiology and Audiometry Evaluation and Diagnostic Services” in this handbook.

2.2.2.3Abnormal Hearing Screening Results

If the screening returns abnormal results, the client must be referred to a Texas Medicaid-enrolled provider who is a licensed audiologist or physician who provides audiology services. Clients who are 20 years of age or younger and have abnormal screening results must be referred to a Texas Medicaid-enrolled provider who is an audiologist or physician who is experienced with the pediatric population and who offers auditory services.

The referring physician who performs the screening must complete the Physician’s Examination Report, which is maintained in the client’s medical record. A new Physician’s Examination Report must be completed whenever there is a change in the client’s hearing or a new hearing aid is needed. Retro­spective review may be performed to ensure documentation supports the medical necessity of the service.

In addition to being referred to an appropriate provider for further testing, clients who are 35 months of age and younger and have suspected hearing loss must be referred to Early Childhood Intervention (ECI) as soon as possible but no longer than 7 days after identification, even if the client was referred to an appropriate provider for further testing.

Refer to:  Subsection 2.8, “Early Childhood Intervention (ECI) Services” in the Children’s Services Handbook (Vol. 2, Provider Handbooks) for more information about ECI.

2.2.3Audiology and Audiometry Evaluation and Diagnostic Services

Audiometry is a benefit of Texas Medicaid for clients of any age. Physicians must recommend hearing evaluations based on examination of the client. Only physicians or licensed audiologists will be reimbursed for hearing evaluations. Hearing aid fitters and dispensers are not reimbursed for hearing evaluations.

Important:The date of service for audiology and audiometry evaluations and diagnostic services is the date the service is rendered to the client. The date of service that is billed on the claim must match the date of service that is documented in the client’s medical record.

The following audiometry procedure codes are benefits of Texas Medicaid for a basic comprehensive audiometry survey:

Procedure Codes

92550

92551

92552

92553

92555

92556

92557

The following additional procedure codes may be benefits for audiometric testing:

Procedure Codes

92558

92563

92565

92567

92568

92570

92571

92572

92575

92576

92578

92579

92582

92583

92584

92585

92586

92587

92588

Refer to:  The appropriate Texas Medicaid fee schedule on the TMHP web site at www.tmhp.com for procedure codes that may be reimbursed to individual types of providers.

Auditory brainstem response (ABR) and otoacoustic emissions (OAE) are benefits for clients of any ages when performed to identify and diagnose hearing loss and for newborns when performed for the purpose of a newborn hearing screening.

Note:ABR and OAE tests performed as part of the newborn hearing screen are reimbursed as part of the hospital visit and are not reimbursed separately.

2.2.3.1Otological Examinations

Otological examinations are a benefit when medically necessary and provided by a Medicaid-enrolled physician licensed to perform this service.

Procedure codes 92504 and 92505 are benefits for otological examinations.

An otological examination may also include physician evaluation and management (E/M) services provided to diagnose or treat medical conditions.

Refer to:  Subsection 9.2.56.4, “Group Clinical Visits” in the Medical and Nursing Specialists, Physi­cians, and Physician Assistants Handbook (Vol. 2, Provider Handbooks) for information about medically necessary physician E/M services.

2.2.3.2Vestibular Evaluations

Vestibular evaluations are a benefit when medically necessary and provided by a Medicaid-enrolled physician or nonphysician provider licensed to perform this service.

The following procedure codes for vestibular evaluations are benefits:

Procedure Codes

92531

92532

92533

92534

92537

92538

92540

92541

92542

92544

92545

92546

92547

2.2.3.3Forms and Documentation

Providers of hearing evaluations must have a report in the client’s record. Providers must include in the report hearing evaluation test data. The Hearing Evaluation, Fitting, and Dispensing Report (Form 3503) must be completed by the physician or audiologist who conducts the diagnostic testing. The provider who signs the report must maintain it in the client’s file. The report includes audiometric assessment results of the hearing evaluation and must provide objective documentation that amplifi­cation improves communication ability. Retrospective review may be performed to ensure documentation supports the medical necessity of the service.

For physician diagnostic hearing services (procedure codes 92502, 92504, 92540, 95940, and 95941), providers must maintain documentation of medical necessity in the client’s medical record. Retro­spective review may be performed to ensure that the documentation supports medical necessity for the service.

2.2.3.4Prior Authorization

Hearing screening and testing services do not require prior authorization. Documentation of medical necessity must be maintained by the provider in the client’s medical record. Retrospective review may be performed to ensure that the documentation supports medical necessity for the service.

2.2.3.5Limitations

Newborn hearing screenings provided during the birth admission are considered part of the newborn delivery payment to the facility and are not reimbursed as separate procedures.

An otological examination is a benefit of Texas Medicaid when medically necessary and provided by a Medicaid-enrolled physician licensed to perform this service.

An otological examination may also include physician E/M services provided to diagnose or treat medical conditions.

Refer to:  Subsection 9.2.56.4, “Group Clinical Visits” in the Medical and Nursing Specialists, Physi­cians, and Physician Assistants Handbook (Vol. 2, Provider Handbooks) for information about medically necessary physician E/M services.

Audiometry survey procedure codes and evoked potential and otoacoustic emissions screening procedure codes may be reimbursed once per day.

Procedure code 92568 may be reimbursed when billed with one of the following diagnosis codes:

Diagnosis Codes

D333

G510

G511

G518

G519

H8001

H8002

H8003

H8011

H8012

H8013

H8021

H8022

H8023

H8081

H8082

H8083

H8091

H8092

H8093

H8101

H8102

H8103

H8111

H8112

H8113

H8121

H8122

H8123

H81311

H81312

H81313

H81319

H81391

H81392

H81393

H8141

H8142

H8143

H818X1

H818X2

H818X3

H8191

H8192

H8193

H8301

H8302

H8303

H8311

H8312

H8313

H832X1

H832X2

H832X3

H838X1

H838X2

H838X3

H838X9

H8391

H8392

H8393

H900

H9011

H9012

H902

H903

H9041

H9042

H905

H906

H9071

H9072

H908

H90A11

H90A12

H90A21

H90A22

H90A31

H90A32

H9101

H9102

H9103

H9121

H9122

H9123

H918X1

H918X2

H918X3

H9191

H9192

H9193

H9311

H9312

H9313

H93211

H93212

H93213

H93221

H93222

H93223

H93231

H93232

H93233

H93241

H93242

H93243

H93291

H93292

H93293

H933X1

H933X2

H933X3

H933X9

Q179

R42

Providers may bill only one of the pure tone audiometry procedure codes (92551, 92552, and 92553) per day, any provider.

Procedure codes 92553 and 92556 are not reimbursed on the same day by any provider. If these procedure codes are billed for the same date of service, they are denied with instructions to bill with the more appropriate, comprehensive audiometry procedure code 92557.

Tympanometry

Tympanometry (procedure code 92567) must be limited to selected individual cases where its use demonstrably adds to the provider’s ability to establish a diagnosis and provide appropriate treatment. Tympanometry is limited to three services per rolling year when billed by any provider and is based on medical necessity, which must be documented in the client’s medical record.

Electrical Testing

Electrical testing may be reimbursed for services rendered to clients of any age.

Electrical testing (procedure code 92547) must be billed with the same date of service by the same provider as procedure code 92541, 92542, 92544, 92545, or 92546.

Vestibular Evaluation

Vestibular evaluation is a benefit of Texas Medicaid when medically necessary and provided by a provider who is licensed to provide this service.

Hearing pathway tests such as audiometry, ABR, and electrocochleography (ECoG) can also be used for the same purpose and are frequently combined with vestibular tests.

ABR and OAE Hearing Screening Services

Evoked response testing (procedure codes 92558, 92585, 92586, 92587, and 92588) is considered a bilateral procedure. If separate charges are billed for left- and right-sided tests of the same type, the tests are combined and reimbursed as a quantity of one. An electroencephalogram (EEG) may be reimbursed for the same date of service as evoked response testing by any provider.

Procedure code 92591 may be reimbursed as often as is medically necessary.

Texas Medicaid may reimburse physicians for ear and throat examination procedure codes 92502, 92504, and 92540. Audiologists will not be reimbursed for these services.

Refer to:  Subsection 9.2.56, “Physician Evaluation and Management (E/M) Services” in the Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook (Vol. 2, Provider Handbooks) for more information about these services.

Procedure codes 95940 and 95941 may be reimbursed in addition to each evoked potential test. Procedure codes 95940 and 95941 are limited to a maximum of 2 hours per day, per client, any provider, without documentation of medical necessity. Procedure codes 95940 and 95941 cannot be reported by the surgeon or anesthesiologist.

2.2.3.6SHARS Audiology Services

Audiology evaluation and therapy services procedure codes 92507, 92508, 92521, 92522, 92523, 92524, and 92620 may be reimbursed to school districts and state agencies that are enrolled with Texas Medicaid as SHARS providers.

Refer to:  Section 3, “School Health and Related Services (SHARS)” in the Children’s Services Handbook (Vol. 2, Provider Handbooks) for more information about SHARS services.

Other hearing evaluation, diagnostic, and hearing aid services may be reimbursed to appropriately-enrolled audiologists, hearing aid fitters and dispensers, and physicians as outlined in this section.

2.2.3.7Noncovered Services

Texas Medicaid does not reimburse for a hearing screening completed for day care, Head Start, or school unless it is part of an acute-care visit in a clinic setting. Separate procedure codes must not be billed for these services.

2.2.4Hearing Aid Devices and Accessories (Nonimplantable)

Texas Medicaid may reimburse hearing aid fitters and dispensers for the following devices and accessories:

Service

Limitation

Hearing aid devices

Limitation: 

For clients who are 20 years of age and younger, 1 hearing aid device per ear may be reimbursed every 5 years from the month it is dispensed.

For clients who are 21 years of age and older, if the client has at least a 35 dB hearing loss in both ears, 1 hearing aid device may be reimbursed every 5 years from the month it is dispensed. Either the left or the right may be reimbursed, but not both in the same 5 year period.

 

Refer to:  Subsection 2.2.4.1, “Forms and Documentation” in this handbook for additional medical necessity criteria.

Replacement hearing aid devices that are required within the same 5-year period must be prior authorized.

Repairs or modifications may be reimbursed without prior authorization once per year after the 1-year warranty period has lapsed if the requested repair or modification is a better alternative than a new purchase.

 

Procedure codes: See below for monaural and binaural procedure codes.

Procedure code V5014 may be reimbursed for repairs and modifications.

Date of service: The date of service for the initial hearing aid device is the date the client successfully completes the 30-day trial period and accepts the hearing aid device.

Note:During the warranty period, Texas Medicaid may reimburse providers for a replacement hearing aid and replacement hearing aid batteries. Texas Medicaid will not reimburse hearing aid repairs or modifications that are rendered during the 12-month manufacturer’s warranty period. Providers must follow the manufacturer’s repair process as outlined in their warranty contract.

Hearing aid accessories

Limitation: As often as is medically necessary for clients who are 20 years of age and younger with prior authorization.

Note:Hearing aid accessories include, but are not limited to, chin straps, clips, boots, and headbands.

Procedure code: V5267

Date of service: The date of service is the date the client successfully completes the 30-day trial period and accepts the hearing aid device or the date the client receives the replacement accessory item.

Ear impression

Limitation: 1 each per hearing aid device as follows:

For one impression, bill a quantity of 1.

For two impressions, bill a quantity of 2.

Procedure codes: V5275

Date of service: The date of service for the ear impression is the date the ear impression is taken.

Ear mold

Limitation: As medically necessary for clients who are 20 years of age and younger.

For clients who are 21 years of age and older:

3 ear molds per rolling year for custom ear molds

4 ear molds per rolling month for disposable ear molds

Ear molds must be billed using the appropriate LT or RT modifier. Replacement ear molds may be reimbursed as often as is medically necessary without prior authorization. Documentation of medical necessity must be maintained in the client’s medical record.

 

Procedure codes: V5264 and V5265

Date of service: The date of service for the ear mold is the date the ear mold is taken.

Batteries (Replacement only)

Limitation: Replacement batteries may be reimbursed as often as is medically necessary when a hearing aid device has been previously reimbursed by Texas Medicaid.

Note:If a hearing aid has not been reimbursed by Texas Medicaid in the last 5 years, the replacement batteries may be reimbursed on appeal with a statement that documents medical necessity.

Procedure code: V5266

Date of service: The date of service is the date the client receives the replacement batteries.

The following monaural procedure codes may be reimbursed for medically necessary hearing aid devices and replacements that are rendered to clients of any age when they are billed with the appro­priate modifier LT or RT to indicate for which ear the hearing aid device was purchased and fitted:

Procedure Codes

V5030

V5040

V5244

V5245

V5246

V5247

V5254

V5255

V5256

V5257

V5298

Procedure codes V5170 and V5180 may be reimbursed for monaural hearing aids that are rendered to clients who are 20 years of age and younger only.

The following binaural procedure codes may be reimbursed for medically necessary hearing aid devices and replacements that are rendered to clients who are 20 years of age and younger:

Procedure Codes

V5100

V5210

V5220

V5249

V5250

V5251

V5252

V5253

V5258

V5259

V5260

V5261

V5298

Binaural hearing aid procedure codes must be submitted with a quantity of 1 per procedure code. Providers can refer to the Online Fee Lookup (OFL) or the applicable fee schedule on the TMHP website at www.tmhp.com for reimbursement rates.

Refer to:  Subsection 2.4.2, “Reimbursement” in this handbook for more information about manual pricing.

2.2.4.1Forms and Documentation

Monaural hearing aids may be reimbursed for clients who have no medical contraindication for using a hearing aid and who have documentation of medical necessity. The following documentation of medical necessity must be maintained in the client’s medical record:

Hearing loss in the better ear of 35 dB or greater for the pure tone average of 500, 1000, 1500, and 2000 Hz, or a spondee threshold in the better ear of 35 dB or greater when pure tone thresholds cannot be established

Documentation of communication need and a statement that the patient is alert and oriented and able to use the device appropriately by themselves or with assistance

Clients who are 21 years of age and older must meet the medical necessity criteria outlined above and have at least a 35 dB hearing loss in both ears to qualify for the purchase of a monaural hearing aid device.

Clients who are 20 years of age and younger must meet the medical necessity criteria outlined above and have at least a 35 dB hearing loss in both ears to qualify for the purchase of binaural hearing aid devices.

Claims for non-implantable hearing aid devices must be submitted with a manufacturer invoice showing the net acquisition cost of the non-implantable hearing aid device.

An invoice printed from an email or the Internet will not be accepted and should not be submitted with the claim as documentation to show the net acquisition cost of the hearing aid device unless the invoice reflects the actual price the provider paid for the hearing aid device.

Note:The requirement to submit the net acquisition cost of the hearing aid device applies only to non-implantable monaural and binaural hearing aid devices including, but not limited to, procedure code V5298.

Refer to:  Subsection 6.3.1.1, “Place of Service (POS) Coding” in “Section 6: Claims Filing” (Vol. 1, General Information) for more information about coding place of service for other locations.

2.2.4.2Prior Authorization

Prior authorization is not required for medically necessary hearing aid devices and supplies that are provided within the limitations outlined in the table above.

Prior authorization is required for the following:

Replacement hearing aid devices that are required within the same 5-year period. A replacement hearing aid device may be considered for prior authorization when loss or irreparable damage has occurred. A copy of the police or fire report, when appropriate, and measures to be taken to prevent reoccurrence must be submitted with the prior authorization request. Replacements will not be authorized when the equipment has been abused or neglected by the client, the client’s family, or the caregiver.

Hearing aid accessories for clients who are birth through 20 years of age. Requests for prior autho­rization for children’s hearing aid accessories including, but not limited to, chin straps, clips, boots, and headbands will be considered when the requests are submitted with documentation that shows that the client is birth through 20 years of age and that the requested supply is medically necessary for the proper use or functioning of the hearing aid device.

Hearing aid devices that are not currently a benefit of Texas Medicaid but that are medically necessary for clients who are birth through 20 years of age (using procedure code V5298). 

The prior authorization request must include:

The medical necessity for the requested hearing aid device.

The name of the manufacturer.

The model number, serial number, and the dates that the warranty is in effect for the requested hearing aid.

Additional medically necessary repairs or modifications beyond 1 per year.
For additional repairs or modifications, requests for prior authorization must include documen­tation that supports the need for the requested repair.

For services that require prior authorization, prior authorization must be obtained before the services are rendered. The prior authorization number must be included on the claim form when the claim is submitted to TMHP.

Prior authorization requests must be submitted to the TMHP Special Medical Prior Authorization (SMPA) Department with documentation that supports medical necessity for the requested device, service, or supply. Authorization may be submitted on the TMHP website at www.tmhp.com or by fax to 1-512-514-4213.

Important:For clients who are birth through 20 years of age, if the authorization request is denied because it does not meet benefit criteria, the TMHP SMPA Department will refer the request to the TMHP Comprehensive Care Program (CCP) Department for consideration under CCP. The provider is not required to complete additional forms or request referral to the TMHP CCP Department.

Providers may use the form of their choice to submit the required information to the TMHP SMPA Department. No specific request form is required.

Refer to:  “Section 6: Claims Filing” (Vol. 1, General Information) for more information about the authorizations and claims filing processes.

2.2.4.3Limitations

The following services and supplies must be provided to Texas Medicaid clients if a nonimplantable hearing aid device is medically necessary:

An individual client assessment to identify the appropriate type of device

The fitting/implantation of the device

The re-assessment to determine whether the device allows for adequate hearing

Expendable supplies that are necessary to keep the device functioning properly, such as batteries and accessories

A hearing aid dispensed through Texas Medicaid must meet the following criteria:

Be a new and current model

Meet the performance specifications indicated by the manufacturer

Include, at minimum, a standard 12-month warranty that begins on the dispensing date of the hearing aid.

Providers must dispense each hearing aid reimbursed through Texas Medicaid with all necessary hearing aid accessories and supplies, including a 1-month supply of batteries. The reimbursement for monaural and binaural procedure codes includes the required hearing aid package as follows, and no separate reimbursement will be made for these items:

Acquisition cost of the hearing aid (the actual cost or net cost of the hearing aid after any discounts or rebates have been deducted)

Manufacturer’s postage and handling charges, including shipping insurance

All necessary hearing aid accessories or supplies

Instructions for care and use

A 1-month supply of batteries

Note:TMHP does not supply the hearing aid devices, supplies, and accessories. Providers must purchase equipment directly from manufacturers and submit claims to TMHP for reimbursement using the appropriate procedure codes.

Procedure code V5298 may be reimbursed with prior authorization for hearing aid devices that are not currently a benefit of Texas Medicaid but that are medically necessary for clients who are birth through 20 years of age.

Services for residents in a skilled nursing facility (SNF), intermediate care facility (ICF), or extended care facility (ECF) must be ordered by the attending physician. The order must be on the client’s chart, must state the condition that necessitates the hearing aid services, and must be signed by the attending physician.

2.2.5Hearing Aid Services

The following additional hearing aid related procedures are benefits for services that are rendered to clients of any age:

Procedure Codes

92590

92592

92594

V5010

V5011

V5264

V5265

V5275

The following additional hearing aid related procedures are benefits for services that are rendered to clients who are 20 years of age and younger only:

Procedure Codes

92591

92593

92595

Texas Medicaid may reimburse hearing aid fitters and dispensers for the following services:

Service

Limitation

Hearing test for sensitivity

Limitation: As often as is medically necessary

Procedure code: 92564 (SISI hearing test)

Fitting and dispensing visits

Limitation: 1 fitting per hearing aid procedure code per 5 rolling year period, regardless of the number of times a device is returned as unacceptable during a 30-day trial period

Procedure code: V5011

Limitation: 1 dispensing fee each time a hearing aid is dispensed and a new 30-day trial period begins

Procedure codes: V5090 and V5241 (for clients of any age) and V5110, V5160, V5200, and V5240 (for clients who are 20 years of age and younger)

The dispensing fee may be reimbursed separately from the fitting of the hearing aid.

The post-fitting check is included in the reimbursement for the dispensing procedure and is not reimbursed separately.

Revisit(s)

Limitation: 2 per calendar year when billed by any provider

Procedure codes: 92592 (first and second revisits for monaural fittings for clients of any age) and 92593 (first and second revisits for binaural fittings for clients who are 20 years of age and younger)

Note:Services for Texas Medicaid clients who are 21 years of age and older and who received 2 hearing aid devices (binaural) on or before October 1, 2012, may be reimbursed to the client’s treating physician or audiologist using procedure codes 99211 and 99212.

Hearing aid revisits are limited to a total of two per calendar year by any provider.

2.2.5.1Forms and Documentation

The forms and documentation required for the fitting and dispensing visits are as follows:

Physician Examination Report

Hearing Evaluation, Fitting, and Dispensing Report (Form 3503)

Client acknowledgement statement (created by the provider)

30-day trial period certification statement (created by the provider)

Additional necessary documentation

Physician’s Examination Report—The referring physician who performs the screening must complete the Physician’s Examination Report, which is maintained in the client’s medical record.

Hearing Evaluation, Fitting, and Dispensing Report (Form 3503)—The Hearing Evaluation, Fitting, and Dispensing Report (Form 3503) must be completed by the fitter/dispenser that conducts the fitting and dispensing visit. The provider who signs the report must maintain it in the client’s file. The report includes audiometric assessment results of the hearing evaluation and must provide objective documen­tation to support improved communication ability with amplification. Retrospective review may be performed to ensure documentation supports the medical necessity of the device, service, or supply.

Client Acknowledgement Statement (created by the provider)—At the time the hearing aid device and supplies are dispensed, the client must sign a client acknowledgement statement to verify the client was evaluated and offered an appropriate hearing aid that meets the client’s hearing need. The acknowl­edgement statement must include language that indicates the client is responsible for paying any hearing aid rental fees if charged. The provider must obtain the signed acknowledgment statement before dispensing the hearing aid device and supplies and must keep the signed acknowledgment statement in the client’s file. Retrospective review may be performed to ensure documentation supports the medical necessity of the device, service, or supply.

30-Day Trial Period Certification Statement (created by the provider)—Fitters and Dispensers must inform clients in writing of the trial period lasting 30 consecutive days. The statement, which must be created by the provider and signed by the client, must contain the start and end dates of the trial period, all charges and fees associated with the trial period, an acknowledgment that the client accepts respon­sibility for any assessed rental fees, and the name, address, and telephone number of the State Board of Examiners for Speech-Language Pathology and Audiology. The client must receive a copy of this agreement.

After at least 30 days and the successful completion of the trial period, the provider must update the statement to indicate that the trial was successful and the client accepted the dispensed hearing aid device. The updated statement must be maintained in the client’s file. Retrospective review may be performed to ensure documentation supports the medical necessity of the device, service, or supply.

For hearing aids that are dispensed in a provider’s office, if a client fails to return by the end date of the trial period, the provider must contact the client. After 3 attempts have been made, if the client does not return to the provider’s office, the provider must document all attempts to contact the client and must maintain this documentation in the client’s file. Retrospective review may be performed to ensure documentation supports the contact attempts and the client’s failure to return to the provider’s office. This requirement does not apply for services that are rendered to clients who receive hearing aids in other places of service (i.e., nursing homes)

2.2.5.2Prior Authorization

Prior authorization is not required for fitting and dispensing visits and revisits.

2.2.5.3Limitations

The following hearing aid visits may be reimbursed by Texas Medicaid:

The fitting and dispensing visits that encompass a 30-day trial period and include a post-fitting check 5 weeks after the trial period has been successfully completed

A first revisit as needed after the post-fitting check

A second revisit as needed after the first revisit

The fitting visit includes the fitting, dispensing, and post-fitting check of the hearing aid.

Providers must allow each Texas Medicaid client a 30-consecutive-day trial period that begins with the dispensing date. This trial period gives the client time to determine whether the hearing aid device meets the client’s needs. If the client is not satisfied with the purchased hearing aid, the client may return it to the provider, who must accept it. If the device is returned within 30 days of the date it was dispensed, the provider may charge the client a rental fee not to exceed $2 per day. This fee is not a benefit of Texas Medicaid and will not be reimbursed. The client is responsible for paying the hearing aid rental fees if the provider chooses to charge a fee for the rental of returned hearing aid devices.

During the trial period, providers may dispense additional hearing aids as medically necessary until either the client is satisfied with the results of the hearing aid or the provider determines that the client cannot benefit from the dispensing of another hearing aid. The dispensing date of each additional hearing aid starts a new trial period.

The licensed audiologist or fitter/dispenser must perform a post-fitting check of the hearing aid within 5 weeks of the initial fitting.

The first and second revisits are available if additional visits are required after the post-fitting check.

First revisit. The first revisit must include a hearing aid check.

Second revisit. The second revisit is available as needed after the post-fitting check and first revisit. The second revisit must include either a real ear measurement or aided sound field testing according to the guidelines specified for the hearing evaluation. If the aided sound field test scores suggest a decrease in hearing acuity, the provider must include puretone and speech audiometry readings from the first evaluation.

Home visit hearing evaluations and fittings are permitted only with the physician’s written recommendation.

Services for residents in an SNF, ICF, or ECF must be ordered by the attending physician. The order must be on the client’s chart, must state the condition that necessitates the hearing aid services, and must be signed by the attending physician.

2.3Documentation Requirements

All services, including hearing services, require documentation to support the medical necessity of the service rendered. Hearing services are subject to retrospective review and recoupment if documentation does not support the service billed.

Required forms for nonimplantable hearing devices and services, which are indicated in the specific sections above, are not submitted with the claim to TMHP, but the forms must be completed and maintained in the client’s medical record and made available upon request by HHSC or TMHP for retro­spective review.

2.4Claims Filing and Reimbursement

2.4.1Claims Filing

Hearing services must be submitted to TMHP in an approved electronic format or on the CMS-1500 paper claim form. Providers may purchase CMS-1500 paper claim forms from the vendor of their choice. TMHP does not supply the forms.

When completing a CMS-1500 paper claim form, all required information must be included on the claim, as information is not keyed from attachments. Superbills, or itemized statements, are not accepted as claim supplements.

Refer to:  Subsection 2.2, “Fee-for-Service Reimbursement Methodology” in “Section 2: Texas Medicaid Fee-for-Service Reimbursement” (Vol. 1, General Information) for more infor­mation about reimbursement.

Subsection 1.6.9, “Billing Clients” in “Section 1: Provider Enrollment and Responsibilities” (Vol. 1, General Information).

“Section 3: TMHP Electronic Data Interchange (EDI)” (Vol. 1, General Information) for information on electronic claims submissions.

Subsection 6.1, “Claims Information” in “Section 6: Claims Filing” (Vol. 1, General Infor­mation) for general information about claims filing.

Subsection 6.5, “CMS-1500 Paper Claim Filing Instructions” in “Section 6: Claims Filing” (Vol. 1, General Information). Blocks that are not referenced are not required for processing by TMHP and may be left blank.

Providers must file all claims electronically or on the appropriate Centers for Medicare & Medicaid Services (CMS) paper claim form after providing the services.

Exception:Claims for non-implantable hearing aid devices must be submitted on the CMS-1500 paper claim form because electronic claim submissions do not allow for the submission of attachments.

Claims must include the following information:

The most appropriate International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis code that represents the purpose for the service.

The most appropriate Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) procedure code(s) that represent the service(s) provided.

The appropriate information as indicated on the provider enrollment letter (Electronic claims must also include the most appropriate attested taxonomy code.)

Note:For Texas Medicaid managed care clients, all hearing aid benefits and otology, and audiometry services are administered by the client’s Medicaid managed care organization (MCO).

2.4.1.1Non-implantable Hearing Aid Devices

To be reimbursed for a non-implantable hearing aid device, providers must submit documentation with the paper claim showing their cost for the hearing aid device. The Texas Health and Human Services Commission (HHSC) requires providers to submit non-implantable hearing aid claims using the CMS-1500 paper claim form because electronic claim submissions do not allow for the submission of attachments.

Providers must use the net acquisition cost as the amount billed on the claim. The net acquisition cost is the actual price the provider paid for the device, including the wholesale cost plus sales tax, shipping and handling, and any reductions resulting from discounts or rebates. Providers must not use usual and customary fees as the amount billed.

The documentation submitted with the claim must be a manufacturer invoice showing the net acqui­sition cost of the non-implantable hearing aid device.

An invoice printed from an email or the Internet will not be accepted and should not be submitted with the claim as documentation to show the net acquisition cost of the hearing aid device unless the invoice reflects the actual price the provider paid for the hearing aid device.

2.4.1.2Third Party Liability

Standard third party liability (TPL) rules apply to all hearing services claims.

Refer to:  “Section 8: Third Party Liability (TPL)” (Vol. 1, General Information).

2.4.2Reimbursement

Hearing aid devices and all hearing and audiological services are reimbursed in accordance with 1 TAC §355.8141. To be reimbursed for both audiology services and hearing aid fitting and dispensing services, audiologists must enroll with Texas Medicaid as audiologists and also as hearing aid fitters and dispensers. Audiology services must be billed using the audiologist provider number and benefit code (for electronic claims only) as indicated on the provider enrollment letter that indicates “Audiologist,” and hearing aid and fitting and dispensing services must be billed with the hearing aid provider number and benefit code (for electronic claims only) as indicated on the provider enrollment letter that indicates “Hearing Aid.”

Requested items that are not represented by a specific procedure code must be prior authorized and are priced manually during the authorization process. Manually priced items for clients who are birth through 20 years of age require prior authorization that must be obtained through the TMHP SMPA Department. The reimbursement will be determined based on either the MSRP less 18 percent or based on the provider’s documented invoice cost if there is no MSRP available.

Manually priced items are indicated with “Note Code 5” in the Texas Medicaid fee schedule.

Texas Medicaid implemented mandated rate reductions for certain services. The OFL and static fee schedules include a column titled “Adjusted Fee” to display the individual fees with all mandated percentage reductions applied. Additional information about rate changes is available on the TMHP website at www.tmhp.com/pages/topics/rates.aspx.

Providers may refer to the OFL or the applicable fee schedule on the TMHP website at www.tmhp.com.

2.4.2.1National Correct Coding Initiative (NCCI) and Medically Unlikely Edit (MUE) Guidelines

The HCPCS and CPT codes included in the Texas Medicaid Provider Procedures Manual are subject to NCCI relationships, which supersede any exceptions to NCCI code relationships that may be noted in the manuals. Providers should refer to the CMS NCCI web page for correct coding guidelines and specific applicable code combinations.

In instances when Texas Medicaid limitations are more restrictive than NCCI MUE guidance, Texas Medicaid limitations prevail.

3 Implantable Hearing Devices and Related Services

3.1Enrollment

To enroll in Texas Medicaid, hearing services professionals who provide implantable hearing devices and services must be appropriately enrolled according to their licensure and scope of practice.

Providers cannot be enrolled if their license is due to expire within 30 days. A current license must be submitted.

3.2Services, Benefits, Limitations and Prior Authorization

Implantable hearing devices, including the cochlear implant device, the auditory brainstem implant (ABI), and the bone anchored hearing aid (BAHA), are benefits of Texas Medicaid for clients of all ages.

The following services and supplies must be provided to Texas Medicaid clients if an implantable hearing aid device is medically necessary:

An individual client assessment to identify the appropriate type of device

The fitting of the device

The reassessment to determine whether the device allows for adequate hearing

Expendable supplies that are necessary to keep the device functioning properly, such as batteries and accessories

3.2.1Cochlear Implants

The following procedure codes may be reimbursed for the cochlear implant device, separate compo­nents, and services:

Procedure Codes

69930

L7368

L8499

L8614

L8615

L8616

L8617

L8618

L8619

L8621

L8622

L8623

L8624

L8627

L8628

L8629

The following procedure codes may be reimbursed for diagnostic analysis of the cochlear implant:

Procedure Codes

92601

92602

92603

92604

3.2.1.1Prior Authorization

Prior authorization is required for the following:

Cochlear implant surgery, device, and replacement parts

Sound processor repair or replacement

Battery recharger unit

Replacement batteries beyond the limitations outlined in the sections below

Requests for prior authorization must be submitted by the provider to the SMPA Department with documentation supporting the medical necessity for the requested device, service, or supply.

Note:Requests for clients who are 20 years of age or younger who do not meet the medical necessity criteria may be considered through Comprehensive Care Program (CCP).

Documentation submitted for review must indicate who will be providing the cochlear implant device (i.e., the facility or the Durable Medical Equipment (DME) or medical supplier). The supplier’s provider number must be included on the prior authorization request.

Prior authorization for a unilateral or bilateral cochlear implant may be granted for clients who are 12 months of age and older with documentation of all of the following criteria:

Cognitive ability to use auditory cues and written documentation of agreement by the client or the client’s parent or guardian that the client will participate in a program of post-implantation auditory rehabilitation. This documentation must be maintained in the client’s medical record.

Postlingual deafness or prelingual deafness.

Freedom from middle-ear infection, an accessible cochlear lumen that is structurally suited to implantation, and freedom from lesions in the auditory nerve and acoustic areas of the central nervous system.

No contraindications to surgery.

Inability to derive benefit from appropriately fitted hearing aid devices.

Documentation of poor speech discrimination and a recommendation for cochlear implant candidacy and the most appropriate ICD-10-CM diagnoses for severe-to-profound bilateral senso­rineural hearing loss.

The initial lithium ion battery recharger unit, additional medically necessary units, and additional replacement batteries beyond the limitations indicated in the following sections may be reimbursed with prior authorization. Documentation must be submitted with the prior authorization request to support medical necessity for the request.

Refer to:  Subsection 3.2.4, “Sound Processor Replacement and Repair” in this handbook for more information about sound processor repair or replacement.

3.2.1.2Limitations

Surgery

Procedure code 69930 with the appropriate modifier LT or RT may be reimbursed for unilateral cochlear implantation. Procedure code 69930 with modifier 50 may be reimbursed for bilateral cochlear implantation performed simultaneously.

Device and Components

Procedure codes L8627, L8628, and L8629 for the cochlear implant device and components may be reimbursed for clients who are 12 months of age and older as follows:

The device must be approved by the Food and Drug Administration (FDA) and be age-appropriate for the client.

One per day may be reimbursed with prior authorization.

The cochlear implant device and the surgery to implant the device may be reimbursed separately.

Replacement Batteries and Related Items

Replacement batteries and related items for the cochlear implant device include non-rechargeable batteries, rechargeable batteries, and recharger units as follows:

Procedure Code

Prior Authorization

Limitation

L8621 (Zink air non-rechargeable)

Not required

Maximum of 50 per month

L8622 (Alkaline non-rechargeable)

Not required

Maximum of 31 per month

L8623 (Lithium ion rechargeable)

Not required

2 batteries per calendar year

L8624 (Lithium ion rechargeable)

Not required

2 batteries per calendar year

L7368 (Battery recharger unit for lithium ion rechargeable batteries)

Required

1 replacement unit every 5 rolling years

Replacement batteries for clients with bilateral cochlear implants and two sound processors may be reimbursed when billed with the applicable battery procedure code and the appropriate LT or RT modifier.

Replacement batteries for the cochlear device are limited to clients with a previously paid cochlear implant procedure, device, or supply. Replacement batteries for clients who did not receive the cochlear implant through Texas Medicaid will be considered for reimbursement on appeal with a physician’s statement documenting medical necessity.

Additional batteries and lithium ion battery recharger units beyond these limitations may be reimbursed with prior authorization.

3.2.1.3Auditory Rehabilitation

Auditory rehabilitation is a benefit of Texas Medicaid when it is medically necessary for clients who have received a surgically implanted hearing device, or who have prelingual or postlingual hearing loss when the treating physician has determined that auditory rehabilitation would be beneficial.

The following procedure codes may be reimbursed for auditory rehabilitation:

Procedure Codes

L92626

92627

92630

92633

One auditory rehabilitation evaluation and 12 visits per six rolling months may be reimbursed without prior authorization. Additional visits during a six rolling month period for clients who are 12 months of age through 20 years of age require prior authorization.

Procedure code 92627 is an add-on procedure, and must be billed with the primary procedure code 92626 to be considered for reimbursement.

Note:Additional therapy services may be a benefit through the Texas Medicaid speech therapy benefit.

Refer to:  The Physical Therapy, Occupational Therapy, and Speech Therapy Services Handbook (Vol. 2, Provider Handbooks) for information about speech therapy.

Frequency modulated (FM) systems are not benefits of Texas Medicaid.

3.2.2Auditory Brainstem Implant (ABI)

The following procedure codes may be reimbursed for the ABI, related components, and services:

Procedure Codes

L92640

L8499

L8614

L8621

L8622

S2235

3.2.2.1Prior Authorization

The following implantable hearing devices and services require prior authorization:

ABI surgery, device, and replacement parts

Sound processor repair or replacement

Replacement batteries beyond the limitations outlined in the sections below

Requests for prior authorization must be submitted to the SMPA Department with documentation supporting the medical necessity for the requested device, service, or supply.

Prior authorization requests and claims for ABI is limited to clients with a condition of neurofibroma­tosis, type II or schwannomatosis.

Refer to:  Subsection 2.2.1, “Limitations and Required Forms” in this handbook for additional infor­mation about replacement batteries.

Subsection 3.2.4, “Sound Processor Replacement and Repair” in this handbook for more information about sound processor repair or replacement.

3.2.2.2Limitations

ABI is a benefit for clients who are 12 years of age and older.

Diagnostic analysis of the ABI (procedure code 92640) is limited to 2 hours per day when billed by any provider.

3.2.3Bone-Anchored Hearing Aid (BAHA)

The following procedure codes must be submitted for the BAHA and related components:

Procedure Codes

69714

69715

69717

69718

L8690

L8691

L8692

L8693

V5266

3.2.3.1Prior Authorization

The following implantable hearing devices and services require prior authorization:

BAHA implant surgery, device, and replacement parts

Sound processor repair or replacement

Requests for prior authorization must be submitted to the SMPA Department with documentation supporting the medical necessity for the requested device, service, or supply.

Prior authorization requests may be granted for clients who are 5 years of age and older with all of the following:

Documentation of previous attempts at hearing aid devices and why these devices are inadequate or have failed

Documentation of scores on hearing tests for bone conduction thresholds and on maximum speech discrimination

Documentation of audiological testing showing good inner ear function

Documentation of a multidisciplinary assessment including physical, cognitive, communicative, and behavioral limitations describing the client’s auditory disability and expected benefit with use of the BAHA implant

Documentation of an appropriate diagnosis.

Benefit-eligible conditions may include, but are not limited to the following:

Conductive hearing loss

Sensorineural hearing loss

Other anomalies of external ear with impairment of hearing

Anomalies of skull and face bones

Refer to:  Subsection 3.2.4, “Sound Processor Replacement and Repair” in this handbook for more information about sound processor repair or replacement.

3.2.3.2Limitations

BAHAs are a benefit for clients who are 5 years of age and older.

Replacement batteries for the BAHA (procedure code V5266) do not require prior authorization. The replacement batteries are limited to clients with a previously paid hearing device. Replacement batteries for clients who did not receive the hearing device through Texas Medicaid will be considered for reimbursement on appeal with a physician’s statement documenting the medical necessity.

Procedure codes L8691, L8692, and L8693 will be denied as part of another service when billed by any provider with the same date of service as procedure code L8690.

Procedure code L8692 for the BAHA device and components may be reimbursed once per day with prior authorization.

Bilateral BAHA procedures are not benefits of Texas Medicaid.

3.2.4Sound Processor Replacement and Repair

3.2.4.1Prior Authorization

Replacement and repair of a sound processor require prior authorization.

Documentation by the provider must explain the need for the replacement of the sound processor. The processor must be used for a minimum of 12 months before replacement of the unit will be considered.

The prior authorization request must include evidence of the purchase, such as the manufacturer’s warranty.

Repair of a sound processor will be considered for prior authorization with documentation of medical necessity for the requested repair. Repair of a sound processor will be manually priced at the time the prior authorization is reviewed and granted. If the actual cost of the repair differs from the prior autho­rized fee, the provider must contact the SMPA Department to update the authorization before filing a claim for the repair services.

3.2.4.2Limitations

Procedure code L8499 with modifier RB may be reimbursed for sound processor repair.

Repair or replacement of a sound processor is not a benefit during the manufacturer’s warranty period.

3.2.5Electromagnetic Bone Conduction Hearing Device - Removal Only

The removal of the electromagnetic bone conduction hearing aid may be reimbursed by Texas Medicaid using procedure code 69711.

The removal or repair of an electromagnetic bone conduction hearing device is limited to two proce­dures per lifetime when billed by any provider.

The implantation of the device is not a benefit of Texas Medicaid.

3.3Documentation Requirements

All implantable hearing aid services require documentation to support the medical necessity of the service rendered. Hearing services are subject to retrospective review and recoupment if documentation does not support the service billed.

3.4Claims Filing and Reimbursement

3.4.1Claims Filing

Hearing services must be submitted to TMHP in an approved electronic format or on the CMS-1500 paper claim form. Providers may purchase CMS-1500 paper claim forms from the vendor of their choice. TMHP does not supply the forms.

When completing a CMS-1500 paper claim form, all required information must be included on the claim, as information is not keyed from attachments. Superbills, or itemized statements, are not accepted as claim supplements.

Refer to:  Subsection 2.2, “Fee-for-Service Reimbursement Methodology” in “Section 2: Texas Medicaid Fee-for-Service Reimbursement” (Vol. 1, General Information) for more infor­mation about reimbursement.

Subsection 1.6.9, “Billing Clients” in “Section 1: Provider Enrollment and Responsibilities” (Vol. 1, General Information).

“Section 3: TMHP Electronic Data Interchange (EDI)” (Vol. 1, General Information) for information on electronic claims submissions.

Subsection 6.1, “Claims Information” in “Section 6: Claims Filing” (Vol. 1, General Infor­mation) for general information about claims filing.

Subsection 6.5, “CMS-1500 Paper Claim Filing Instructions” in “Section 6: Claims Filing” (Vol. 1, General Information). Blocks that are not referenced are not required for processing by TMHP and may be left blank.

Note:For Texas Medicaid managed care clients, all implantable hearing devices and services are administered by the client’s Medicaid MCO.

3.4.1.1Third Party Liability

Standard TPL rules apply to all hearing services claims.

Refer to:  “Section 8: Third Party Liability (TPL)” (Vol. 1, General Information).

3.4.2Reimbursement

Implantable hearing aids and related services are reimbursed in accordance with 1 TAC §355.8141.

Implantable hearing aids and related services are reimbursed at the lesser of the billed charges or the published Texas Medicaid fee. Unless otherwise indicated, providers may not make additional charges to the client for covered services; such charges constitute a breach of the Texas Medicaid contract.

Requested items that are not represented by a specific procedure code must be prior authorized and are priced manually during the authorization process. Manually priced items for clients who are birth through 20 years of age require prior authorization that must be obtained through the TMHP SMPA Department. The reimbursement will be determined based on either the MSRP less 18 percent or based on the provider’s documented invoice cost. Manually priced items are indicated with “MP” in the reimbursement rate table at the end of this article.

Texas Medicaid implemented mandated rate reductions for certain services. The OFL and static fee schedules include a column titled “Adjusted Fee” to display the individual fees with all mandated percentage reductions applied. Additional information about rate changes is available on the TMHP website at www.tmhp.com/pages/topics/rates.aspx.

Providers may refer to the OFL or the applicable fee schedule on the TMHP website at www.tmhp.com.

3.4.2.1NCCI and MUE Guidelines

The HCPCS and CPT codes included in the Texas Medicaid Provider Procedures Manual are subject to NCCI relationships, which supersede any exceptions to NCCI code relationships that may be noted in the manuals. Providers should refer to the CMS NCCI web page for correct coding guidelines and specific applicable code combinations.

In instances when Texas Medicaid limitations are more restrictive than NCCI MUE guidance, Texas Medicaid limitations prevail.

4 Vision Care Professionals

4.1Enrollment

To enroll in Texas Medicaid, optometrists (doctors of optometry [ODs]) and ophthalmologists must be licensed by the licensing board of their profession to practice in the state where the service is performed, at the time the service is performed, and be enrolled as Medicare providers.

An optometrist or ophthalmologist cannot be enrolled if their license is due to expire within 30 days; a current license must be submitted.

4.2Provider Responsibilities

Suppliers of eyewear must comply with all Medicaid provider responsibilities and adhere to the following guidelines:

Do not delay the ordering of eyewear or the dispensing of eyeglasses to the client while payment is pending from TMHP.

Deliver the eyewear in a reasonable amount of time (usually two or three weeks from the date the order is placed by the client).

Obtain the required eligibility information from the client’s Your Texas Benefits Medicaid card.

Refer to the Your Texas Benefits Medicaid website at www.yourtexasbenefitscard.com to determine whether eyeglasses have been reimbursed by Texas Medicaid within the last 24 months. Providers are advised to ask clients if they have recently received vision care services that may not appear on the Your Texas Benefits Medicaid website because of the delay in updating form information.

Submit claims for eyewear services as soon as possible so the client’s record indicates that eyewear or eyeglasses have been dispensed.

Have the client, parent, or guardian sign and date the Vision Care Eyeglass Patient (Medicaid Client) Certification Form and retain it in their records. When a client chooses an eyeglass or contact lens option beyond the program limitations, or if nonprosthetic eyeglasses or contact lenses are replaced because of loss or destruction, the client must acknowledge their choice and his/her liability for the cost difference by signing the Vision Care Eyeglass Patient (Medicaid Client) Certi­fication Form. The form must remain in the provider’s records.

Do not charge a Medicaid client more than a patient not enrolled in Texas Medicaid for noncovered services (e.g., tints, oversized lenses, or frames).

Keep invoices on file for a minimum of five years.

Submit claims using the date eyeglasses were ordered as the date of service (DOS) (the start of the 95-day filing period), not the date the eyewear was dispensed.

4.3Services, Benefits, Limitations, and Prior Authorization

Examination and treatment of eye conditions, including prescribing and dispensing of medically necessary eyeglasses or contact lenses, are benefits of Texas Medicaid and may be reimbursed to optom­etrist, ophthalmologist, and optician providers as is within the scope of practice for each.

The following services are included in other services and will not be considered for separate reimbursement:

Vision screening conducted to meet State screening requirements, such as the DSHS School Vision and Hearing Screening Program.

Expenses for medical supplies, equipment, and other items that are not specifically made-to-order for the client are considered to have been incurred on the date the item is delivered.

Ophthalmologist and Optometrist

Examination and treatment services rendered by an ophthalmologist or optometrist are not limited to the procedure codes included in this handbook.

Refer to:  The Texas Medicaid fee schedules on the TMHP web site at www.tmhp.com for a complete list of procedure codes that may be reimbursed by Texas Medicaid.

Optician

Services rendered by an optician are limited to fitting and dispensing of medically necessary eyeglasses and contact lenses.

Note:In accordance with the Omnibus Reconciliation Act of 1986, Section 9336, a Doctor of Optometry is considered a physician, with respect to the provision of any item or service the optometrist is authorized to perform by state law or regulation.

4.3.1Services Performed in Long-Term Care Facilities

Ophthalmological, optometric, and eyeglass or contact lens services provided in a skilled or intermediate care facility may be reimbursed when the client’s attending physician has ordered the service and the signed order is included in the client’s medical record at the nursing facility.

The ordering physician’s name and provider identifier must be documented on the claim when ophthal­mological, optometric, or eyeglasses or contact lenses services are performed in a skilled or intermediate care facility.

4.3.2Services Performed in Federally Qualified Healthcare Centers (FQHC)

Vision services rendered by FQHC providers may be reimbursed based on an all-inclusive rate per visit.

Refer to:  Subsection 2.2, “Services, Benefits, Limitations, and Prior Authorization” in the Clinics and Other Outpatient Facility Services Handbook (Vol. 2, Provider Handbooks) for information about vision services that may be reimbursed to FQHC providers.

4.3.3THSteps Medical Checkup Vision Screening

A vision screening must be completed during each THSteps medical checkup with standardized screenings performed at specific ages, as listed in the THSteps Periodicity Schedule. Providers may perform a vision screening during an acute care visit with the appropriate screening tools or refer at-risk infants and children to an optometrist or ophthalmologist who is experienced with the pediatric population and who can perform further testing, diagnosis, and treatment.

Refer to:  Subsection 5.3.11.2.4, “Vision Screening” in the Children’s Services Handbook (Vol. 2, Provider Handbooks) for information about THSteps medical checkup vision screenings.

4.3.3.1Vision Screening Outside of a THSteps Preventive Care Medical Checkup

Vision screening for clients who are birth through 20 years of age may be completed at any primary care provider’s office visit upon the following:

Request from a parent

Referral from a school vision screening program

Referral from a school nurse

Clients who are birth through 20 years of age must be screened for eye abnormalities by history, obser­vation, and physical exam. Clients who are identified as high risk must be referred to an appropriate Medicaid-enrolled optometrist or ophthalmologist.

4.3.4Noncovered Services

The following services and supplies are not a benefit of Texas Medicaid:

Artificial eyes for clients who are 21 years of age and older.

Note:Artificial eyes for clients who are birth through 20 years may be considered under Texas Health Steps-Comprehensive Care Program (THSteps-CCP).

Eyeglasses for residents of institutions where the reimbursement formula and vendor reimbursement include this service.

Eyeglasses or contact lenses prescribed or dispensed to clients at a hospital or nursing facility without documented orders of the attending physician in the client’s medical records.

Low vision aids.

Note:Clients may be referred to DARS for low vision aids.

Optional eyeglass features that are requested by the client but that do not increase visual acuity
(e.g., lens tint, industrial hardening, and decorative accessories or lettering).

Plano sunglasses.

Extended color vision examination (procedure code 92283), dark adaptation examination (procedure code 92284), and vision screening (procedure codes 99172 or 99173).

Spectacle (eyeglass) fitting services when billed separately.

Clients may be billed for noncovered frames and other items beyond Medicaid benefits. Providers must have the client sign and date the Vision Care Eyeglass Patient (Medicaid Client) Certification Form and retain it in the provider’s records. The client payment amount is not considered other insurance and must not be entered as a credit amount in the electronic field.

Example:Texas Medicaid may reimburse providers a total of $27.93 for eyeglass frames that are within the provider’s selection for Medicaid reimbursement plus the allowed cost per lens. If the client chooses a pair of frames (such as $200 frames) that are outside of the provider’s selections for Medicaid reimbursement and if the client chooses other items or services that are not a benefit of Texas Medicaid (such as tinted lenses for an extra $10 charge), the client is responsible for and may be billed for the balance of the cost of the frames ($172.07) and the other items that are not a benefit of Medicaid ($10 for tinted lenses).

The provider may withhold the noncovered eyewear, contacts, or eyeglasses until the client pays for those items. If the client fails to pay for the noncovered items or has not returned for finished eyewear within a reasonable length of time (two to three months), the provider may return any reusable items to stock. Any payment made by TMHP for frames or lenses must be refunded to Texas Medicaid. If a client requests eyewear that is beyond program benefits (for example, scratch-resistant coating), Medicaid allows reimbursement up to the maximum fee. The provider may charge the client the difference between the Medicaid payment and the customary charge for the eyewear requested, when the client has been shown the complete selection of Medicaid-covered eyewear and when the following conditions are met:

The client rejects the Medicaid-covered eyewear and wants eyewear that complies with Texas Medicaid specifications, but is not included in the selection of Medicaid-covered eyewear.

The client indicates a willingness to pay the difference between the Medicaid payment and the actual charge. The provider must have the client sign the Vision Care Eyeglass Patient (Medicaid Client) Certification Form and retain it in the provider’s records.

Note:A client who has been determined by their provider to have a vision impairment that may require intensive or comprehensive vision impaired related services should be referred to the DARS Division for Blind Services for evaluation and any appropriate resources.

4.3.5Vision Testing

Vision testing and examination and treatment of eye conditions are benefits of Texas Medicaid and may be reimbursed to ophthalmologist or optometrist providers.

Eye examinations with refraction testing may be reimbursed using the following procedure codes:

Procedure Codes

S0620

S0621

Medical evaluation and examination may be reimbursed using the following procedure codes:

Procedure Codes

92002

92004

92012

92014

92015

Procedure codes 92002, 92004, 92012, and 92014 are limited to one service per day by any provider.

Refer to:  Subsection 9.2.56.1.1, “New and Established Patient Services” in the Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook (Vol. 2, Provider Handbooks) for information about new patient and established patient E/M services.

Vision testing procedure codes are subject to the CMS NCCI relationships. Claims that are submitted by physicians with the same specialty who are in the same group practice are processed as if they were the same provider. Providers should refer to the Current Procedural Terminology (CPT) Manual for additional information about intermediate and comprehensive ophthalmological services.

4.3.5.1Routine Vision Testing

Procedure codes S0620 and S0621 may be reimbursed for routine vision testing with refraction when they are billed with diagnosis code Z0100 or Z0101.

Procedure codes S0620 and S0621 will be denied if billed with the same date of service as procedure code 92020.

Clients who are birth through 20 years of age are eligible for a routine eye examination with refraction testing for the purpose of obtaining eyeglasses or contact lenses once every 12 months. The limitation for refraction testing can be exceeded for clients who are birth through 20 years of age only when:

The parent, teacher, or school nurse requests the refraction testing and it is medically necessary.

There is a significant change in vision, and documentation supports a diopter (d) change of 0.5d or greater in the sphere, cylinder, prism measurements, or axis changes.

Clients who are 21 years of age and older are eligible for a routine eye examination with refraction testing for the purpose of obtaining eyeglasses or contact lenses once every 24 months. The limitation for refraction testing can be exceeded for clients who are 21 years of age and older only when there is a significant change in vision, and documentation supports a diopter change of 0.5d or more in the sphere, cylinder, prism measurements, or axis changes.

4.3.5.2Medically Necessary Eye Examinations

An eye examination with or without refraction (procedure code 92002, 92004, 92012, 92014, or 92015) may be reimbursed for medical evaluations and examinations of the eye. Procedure codes 92002, 92004, 92012, 92014, and 92015 will not be reimbursed for routine exams.

Documentation in the client’s medical record must support the medical necessity of the service performed.

Procedure codes 92002, 92004, 92012, and 92014 may be reimbursed when it is medically necessary to ophthalmologist or optometrist providers for medically necessary eye examinations without refraction.

Procedure code 92015 may be reimbursed to ophthalmologist or optometrist providers for refraction in addition to the eye examination procedure code 92002, 92004, 92012, or 92014. A refractive state (procedure code 92015) will be denied as part of another service if it is billed with the same date of service by the same provider as procedure code S0620 or S0621.

4.3.5.3Ophthalmological Examination and Evaluation with General Anesthesia

An ophthalmological examination and evaluation under general anesthesia (procedure codes 92018 and 92019) performed by an ophthalmologist may be medically necessary when a client has significant injury or cannot otherwise tolerate the procedure while conscious.

Procedure codes 92018 and 92019 may be reimbursed once per service, per day, when billed by any provider.

4.3.5.4Ophthalmic 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

76514

76516

76519

76529

76999

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:

Diagnosis Codes

Once Per Lifetime

H40001

H40002

H40003

H40011

H40012

H40013

H40021

H40022

H40023

H40031

H40032

H40033

H40041

H40042

H40043

H40051

H40052

H40053

H40061

H40062

H40063

H4010X0

H4010X1

H4010X2

H4010X3

H4010X4

H401110

H401111

H401112

H401113

H401114

H401120

H401121

H401122

H401123

H401124

H401130

H401131

H401132

H401133

H401134

H401190

H401191

H401192

H401193

H401194

H401210

H401211

H401212

H401213

H401214

H401220

H401221

H401222

H401223

H401224

H401230

H401231

H401232

H401233

H401234

H401310

H401311

H401312

H401313

H401314

H401320

H401321

H401322

H401323

H401324

H401330

H401331

H401332

H401333

H401334

H40141

H40142

H40143

H401510

H401511

H401512

H401513

H401514

H401520

H401521

H401522

H401523

H401524

H401530

H401531

H401532

H401533

H401534

H4020X0

H4020X1

H4020X2

H4020X3

H4020X4

H40211

H40212

H40213

H402210

H402211

H402212

H402213

H402214

H402220

H402221

H402222

H402223

H402224

H402230

H402231

H402232

H402233

H402234

H402290

H40231

H40232

H40233

H40241

H40242

H40243

H4031X0

H4031X1

H4031X2

H4031X3

H4031X4

H4032X0

H4032X1

H4032X2

H4032X3

H4032X4

H4033X0

H4033X1

H4033X2

H4033X3

H4033X4

H4041X0

H4041X1

H4041X2

H4041X3

H4041X4

H4042X0

H4042X1

H4042X2

H4042X3

H4042X4

H4043X0

H4043X1

H4043X2

H4043X3

H4043X4

H4051X0

H4051X1

H4051X2

H4051X3

H4051X4

H4052X0

H4052X1

H4052X2

H4052X3

H4052X4

H4053X0

H4053X1

H4053X2

H4053X3

H4053X4

H4061X0

H4061X1

H4061X2

H4061X3

H4061X4

H4062X0

H4062X1

H4062X2

H4062X3

H4062X4

H4063X0

H4063X1

H4063X2

H4063X3

H4063X4

H40811

H40812

H40813

H40821

H40822

H40823

H40831

H40832

H40833

H4089

H409

H42

H44511

H44512

H44513

Q150

As Medically Necessary

A1859

H1701

H1702

H1703

H1711

H1712

H1713

H17811

H17812

H17813

H17821

H17822

H17823

H1789

H179

H18001

H18002

H18003

H18011

H18012

H18013

H18021

H18022

H18023

H18031

H18032

H18033

H18041

H18042

H18043

H18051

H18052

H18053

H18061

H18062

H18063

H1811

H1812

H1813

H1820

H18211

H18212

H18213

H18221

H18222

H18223

H18231

H18232

H18233

H1830

H18311

H18312

H18313

H18321

H18322

H18323

H18331

H18332

H18333

H1840

H18411

H18412

H18413

H18421

H18422

H18423

H1843

H18441

H18442

H18443

H18451

H18452

H18453

H18461

H18462

H18463

H1849

H1850

H1851

H1852

H1853

H1854

H1855

H1859

H18601

H18602

H18603

H18611

H18612

H18613

H18621

H18622

H18623

H1870

H18711

H18712

H18713

H18791

H18792

H18793

H18831

H18832

H18833

H21551

H21552

H21553

H4040X4

H4041X0

H4041X1

H4041X2

H4041X3

H4041X4

H4042X0

H4042X1

H4042X2

H4042X3

H4042X4

H4043X0

H4043X1

H4043X2

H4043X3

H4043X4

H4720

H47211

H47212

H47213

H4722

H47231

H47232

H47233

H47291

H47292

H47293

H5201

H5202

H5203

Q133

Q134

Q150

T85310A

T85310D

T85310S

T85311A

T85311D

T85311S

T85318A

T85318D

T85318S

T85320A

T85320D

T85320S

T85321A

T85321D

T85321S

T85328A

T85328D

T85328S

T85390A

T85390D

T85390S

T85391A

T85391D

T85391S

T85398A

T85398D

T85398S

Z48810

Z947

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 technical component may be reimbursed once when the service is performed on one or both eyes on the same date of service by any provider.

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:

A clear, concise description of the ophthalmic ultrasound being performed.

A procedure code that is comparable to the ophthalmic ultrasound being requested or the provider’s intended fee for performing the ophthalmic ultrasound.

Note:Services and procedures that are investigational or experimental are not a benefit of Texas Medicaid.

4.3.5.5Corneal Topography

Procedure code 92025 may be reimbursed for corneal topography. Procedure code 92025 is considered medically necessary to diagnose, monitor, and treat various visual conditions such as, but not limited to the following:

Corneal abrasion

Corneal irregularities

Corneal disease

Corneal injury

Keratoconus

Corneal topography may be reimbursed when it is billed with the same date of service by the same provider as an eye examination visit or consultation.

Corneal topography (procedure code 92025) is limited to one service, per day, by any provider and two services per calendar year.

4.3.5.6Gonioscopy

A gonioscopy consists of an eye examination to look at the front part of the eye (anterior chamber) between the cornea and the iris. A microscope (slit lamp) is used to look inside the eye.

Procedure code 92020 may be reimbursed for gonioscopy when billed with one of the diagnosis codes in the following table:

Diagnosis Codes

H40001

H40002

H40003

H40011

H40012

H40013

H40021

H40022

H40023

H40031

H40032

H40033

H40041

H40042

H40043

H40051

H40052

H40053

H40061

H40062

H40063

H4010X0

H4010X1

H4010X2

H4010X3

H4010X4

H401110

H401111

H401112

H401113

H401114

H401120

H401121

H401122

H401123

H401124

H401130

H401131

H401132

H401133

H401134

H401190

H401191

H401192

H401193

H401194

H401210

H401211

H401212

H401213

H401214

H401220

H401221

H401222

H401223

H401224

H401230

H401231

H401232

H401233

H401234

H401310

H401311

H401312

H401313

H401314

H401320

H401321

H401322

H401323

H401324

H401330

H401331

H401332

H401333

H401334

H40141

H40142

H40143

H401510

H401511

H401512

H401513

H401514

H401520

H401521

H401522

H401523

H401524

H401530

H401531

H401532

H401533

H401534

H4020X0

H4020X1

H4020X2

H4020X3

H4020X4

H40211

H40212

H40213

H402210

H402211

H402212

H402213

H402214

H402220

H402221

H402222

H402223

H402224

H402230

H402231

H402232

H402233

H402234

H402290

H40231

H40232

H40233

H40241

H40242

H40243

H4031X0

H4031X1

H4031X2

H4031X3

H4031X4

H4032X0

H4032X1

H4032X2

H4032X3

H4032X4

H4033X0

H4033X1

H4033X2

H4033X3

H4033X4

H4041X0

H4041X1

H4041X2

H4041X3

H4041X4

H4042X0

H4042X1

H4042X2

H4042X3

H4042X4

H4043X0

H4043X1

H4043X2

H4043X3

H4043X4

H4051X0

H4051X1

H4051X2

H4051X3

H4051X4

H4052X0

H4052X1

H4052X2

H4052X3

H4052X4

H4053X0

H4053X1

H4053X2

H4053X3

H4053X4

H4061X0

H4061X1

H4061X2

H4061X3

H4061X4

H4062X0

H4062X1

H4062X2

H4062X3

H4062X4

H4063X0

H4063X1

H4063X2

H4063X3

H4063X4

H40811

H40812

H40813

H40821

H40822

H40823

H4089

H409

H42

Q150

4.3.5.7Sensorimotor Examination

A sensorimotor examination is an evaluation of the function of the ocular neuro-muscular system. This exam includes interpretation and reporting of multiple ocular deviation measurements and includes, but is not limited to, visual motor integration, reversal frequency (letters and numbers), motor speed and precision, visual memory, and visualization to test eye movement and control, focusing ability, eye teaming ability, depth perception, and visual perception skills.

Sensorimotor examination (procedure code 92060) may be reimbursed once per day and twice per calendar year by any provider. Procedure code 92060 may be reimbursed in addition as an eye examination visit.

4.3.5.8Orthoptic or Pleoptic Training

Orthoptics, a component of vision training or vision therapy, are exercises designed to improve the function of the eye muscles with an emphasis on binocular vision and eye movements. Pleoptics are exercises designed to improve impaired vision when there is no evidence of organic eye diseases.

Procedure code 92065 may be reimbursed for orthoptic or pleoptic training when it is billed with one of the following diagnosis codes:

Diagnosis Codes

H50011

H50012

H50021

H50022

H50031

H50032

H50041

H50042

H5005

H5006

H5007

H5008

H50111

H50112

H50121

H50122

H50131

H50132

H50141

H50142

H5015

H5016

H5017

H5018

H5021

H5022

H50311

H50312

H5032

H50331

H50332

H5034

H50411

H50412

H5042

H5043

H5051

H5052

H5053

H5054

H5055

H50611

H50612

H5069

H50811

H50812

H5089

H5111

H5112

H518

H53011

H53012

H53013

H53021

H53022

H53023

H53031

H53032

H53033

H53041

H53042

H53043

H53049

H5501

H5502

H5503

H5504

H5509

H5581

H5589

Orthoptic or pleoptic training may be reimbursed one service per day for up to 6 services when it is billed with one of the diagnosis codes in the above diagnosis table. Up to an additional 6 services may be reimbursed with prior authorization for a total of 12 services per lifetime.

The provider must attest that current therapy has resulted in an improvement with presenting symptomatology over the course of treatment, including, but not limited to:

Blurred vision

Double vision

Amblyopia

Accommodation or near point of convergence measurements

Note:Orthoptic or pleoptic training services over the 12 per lifetime limit may be considered with prior authorization through CCP for clients who are birth through 20 years of age. Documen­tation for medical necessity must be submitted with the prior authorization request.

Procedure code 92065 may be reimbursed in addition to an eye examination visit.

4.3.5.9Special Ophthalmological Services

The following procedure codes may be reimbursed for special ophthalmological services:

Procedure Codes

92081

92082

92083

92100*

92132

92133

92134

92136

*Total component only

Procedure codes 92081, 92082, and 92083 may be reimbursed once per day and twice per calendar year by any provider of any combination.

Procedure codes 92100, 92132, 92133, and 92134 may be reimbursed once per day and twice per calendar year by any provider.

Procedure code 92136 may be reimbursed twice per calendar year by any provider as follows:

The professional interpretation component may be reimbursed when billed with modifier LT or RT to identify the eye on which the service was performed.

The technical component may be reimbursed once when the service is performed on one or both eyes on the same date of service by any provider.

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.

4.3.5.10Ophthalmoscopy and Extended Ophthalmoscopy

Ophthalmoscopy and extended ophthalmoscopy may be reimbursed using the following procedure codes:

Procedure Codes

92225*

92226*

92230*

92235

92240

92242

92250

92260*

* Total component only

Ophthalmoscopy, fluorescein angioscopy, indocyanine-green angiography and fluorescein angiography (procedure codes 92225, 92226, 92230, 92235, 92240, and 92242) 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, 92235, 92240, and 92242 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, 92240, and 92242 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:

Macular degeneration

Glaucoma

Hypertension

Neoplasms of the retina

Choroid (benign or malignant)

Retinal hemorrhages

Ischemia

Retinal detachment

Choroid disturbances

Diabetic retinopathy

Assessment of recently performed retinal laser surgery

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.

4.3.5.11Other Specialized Vision Services

The following procedure codes may be reimbursed by Texas Medicaid when the services are medically necessary:

Procedure Codes

92227*

92228

92265

92270

92275

92285

92286

92287

*Total component only

Procedure codes 92227, 92228, 92265, 92270, 92275, 92285, 92286, and 92287 may each be reimbursed once per day and twice per calendar year by any provider.

External ocular photography (procedure code 92285) may be reimbursed once per day, when it is billed by any provider.

For other professional services, fitting services are included in the reimbursement for prosthetic eyeglasses or contact lenses.

Microfluidic analysis is a CLIA-waived lab test and may be performed by optometrists in the office setting.

Refer to:  Subsection 2.2.16, “Urinalysis and Chemistry” in the Radiology and Laboratory Services Handbook (Vol. 2, Provider Handbooks) for information about microfluidic analysis (procedure code 83861).

4.3.6Nonprosthetic Eyeglasses or Contact Lenses

Nonprosthetic eyeglasses or contact lenses are lenses that are medically necessary to correct defects in vision when the eye’s organic lens is present. Providers may refer to TAC §354.1015 for more information.

Nonprosthetic eyeglasses or contact lenses may be reimbursed for clients of any age when there is no other option available to correct or ameliorate a visual defect. Contact lenses require prior authorization with documentation of medical necessity. Prescribing and dispensing medically necessary eyeglasses or contact lenses are benefits of Texas Medicaid as follows:

Nonprosthetic eyeglasses or contact lenses may be reimbursed once every 24 months. Additional services within the 24-month period may be considered when documentation in the client’s medical record supports medical necessity that includes a diopter change of 0.5d or more in the sphere, cylinder, prism measurements, or axis changes. A new 24 month benefit period for eyewear begins with the placement of the new nonprosthetic eyewear.

Replacement of nonprosthetic eyeglasses or contact lenses because of loss or destruction is a benefit of Texas Medicaid for clients who are birth through 20 years of age. If the eyeglasses or contact lenses are lost or destroyed, the provider must have the client sign the Vision Care Eyeglass Patient (Medicaid Client) Certification Form and the signed form must be maintained in the client’s medical record.

For clients who have had insertion of an intraocular lens (IOL), one pair of eyeglasses or contact lenses may be reimbursed. Additional eyeglasses or contact lenses may be considered when documentation in the client’s medical record supports medical necessity that includes a diopter change of 0.5d or more in the sphere, cylinder, prism measurements, or axis changes.

Note:Because the IOL is considered the prosthetic device, the eyeglasses or contact lenses, and any replacements, are considered nonprosthetic.

Refer to:  Subsection 4.3.5.1, “Routine Vision Testing” in this handbook for information about vision testing for the purposes of prescribing eyewear.

The prescription for eyeglasses must be given to the client upon request. A provider may not withhold a prescription for eyeglasses from a client even if Medicaid reimbursement for the eye examination has not been received.

To be considered by Texas Medicaid, the eyeglasses or contact lenses must be:

Medically necessary.

Prescribed by a doctor of medicine, optometry, or osteopathy.

Prescribed to significantly improve vision or correct a medical condition.

In compliance with eyeglass program specifications for frames and lenses as stated in TAC Rule 354.1017, Specifications for Eyewear and Rule 363.503, Specifications for Eyewear.

Note:Contact lenses require prior authorization unless provided in a medical emergency.

4.3.6.1Eyeglass Lenses and Frames

The following eyeglass lens procedure codes may be billed with frame procedure codes V2020 and V2025 for reimbursement of a pair of eyeglasses:

Procedure Codes

Single Vision Lenses

V2100

V2101

V2102

V2103

V2104

V2105

V2106

V2107

V2108

V2109

V2110

V2111

V2112

V2113

V2114

V2115

V2118

V2121

Bifocal Lenses

V2200

V2201

V2202

V2203

V2204

V2205

V2206

V2207

V2208

V2209

V2210

V2211

V2212

V2213

V2214

V2215

V2218

V2219

V2220

V2221

Trifocal Lenses

V2300

V2301

V2302

V2303

V2304

V2305

V2306

V2307

V2308

V2309

V2310

V2311

V2312

V2313

V2314

V2315

V2318

V2319

V2320

V2321

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

V2410

V2430

V2700

V2710*

V2715*

V2718*

V2730

V2755

V2770

V2780

* Procedure codes for prism correction: prism, slab off, ground in, Fresnell, press-on

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:

Cerebral palsy

Multiple sclerosis

Muscular dystrophy

Epilepsy

Autism

Down’s syndrome

Brain trauma

Balance disorders

Parkinson’s disease

Seizure disorder

Motor ataxia

Marfan’s syndrome

Ocular prostheses

Amblyopia

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

Monocular vision with functional vision in one eye

Retinal detachment or risk for retinal detachment (e.g., lattice degeneration, history of retinal detachment in the family, posterior vitreous detachment)

Procedure code V2784 may be reimbursed when it is billed with one of the following diagnosis codes:

Diagnosis Codes

F840

F843

F845

F848

F849

F951

G20

G2111

G2119

G213

G214

G218

G3183

G3184

G35

G40001

G40009

G40019

G40101

G40109

G40111

G40119

G40201

G40209

G40211

G40219

G40301

G40309

G40311

G40401

G40409

G40411

G40419

G40501

G40509

G40801

G40802

G40803

G40804

G40813

G4089

G40901

G40909

G40911

G40919

G40A01

G40A09

G40A11

G40A19

G40B01

G40B09

G40B11

G40B19

G710

G7111

G7112

G7113

G7114

G7119

G712

G713

G718

G720

G722

G723

G7241

G7249

G7281

G7289

G729

G737

G800

G801

G802

G804

G808

G809

H33001

H33002

H33003

H33011

H33012

H33013

H33021

H33022

H33023

H33031

H33032

H33033

H33041

H33042

H33043

H33051

H33052

H33053

H33191

H33192

H33193

H3321

H3322

H3323

H33301

H33302

H33303

H33311

H33312

H33313

H33321

H33322

H33323

H33331

H33332

H33333

H3341

H3342

H3343

H338

H53001

H53002

H53003

H53011

H53012

H53013

H53021

H53022

H53023

H53031

H53032

H53033

H53041

H53042

H53043

H53049

H540X33

H540X34

H540X35

H540X43

H540X44

H540X45

H540X53

H540X54

H541131

H541132

H541141

H541142

H541151

H541152

H541213

H541214

H541215

H541223

H541224

H541225

H542X12

H542X21

H542X22

H54413A

H54414A

H5442A3

H5442A4

H54512A

H5452A2

H8101

H8102

H8103

H8109

H8110

H8111

H8112

H8113

H8120

H8121

H8122

H8123

H81311

H81312

H81313

H81319

H81391

H81392

H81393

H81399

H8301

H8302

H8303

H8309

H8311

H8312

H8313

H8319

H832X1

H832X2

H832X3

H832X9

P100

P101

P104

P108

P524

P526

P528

Q8740

Q87410

Q87418

Q8742

Q8743

Q900

Q901

Q902

Q909

S06890A

S06890D

S06890S

S06891A

S06891D

S06891S

S06892A

S06892D

S06892S

S06893A

S06893D

S06893S

S06894A

S06894D

S06894S

S06895A

S06895D

S06895S

S06896A

S06896D

S06896S

S06899A

S06899D

S06899S

S069X0A

S069X0D

S069X0S

S069X1A

S069X1D

S069X1S

S069X2A

S069X2D

S069X2S

S069X3A

S069X3D

S069X3S

S069X4A

S069X4D

S069X4S

S069X5A

S069X5D

S069X5S

S069X6A

S069X6D

S069X6S

S069X9A

S069X9D

S069X9S

T8521XA

T8521XD

T8521XS

T8522XA

T8522XD

T8522XS

T8529XA

T8529XD

T8529XS

T85310A

T85310D

T85310S

T85311A

T85311D

T85311S

T85318A

T85318D

T85318S

T85320A

T85320D

T85320S

T85321A

T85321D

T85321S

T85328A

T85328D

T85328S

T85390A

T85390D

T85390S

T85391A

T85391D

T85391S

T85398A

T85398D

T85398S

T8579XA

T8579XD

T8579XS

T85890A

T85890D

T85890S

T85898A

T85898D

T85898S

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:

The client cancels an order for eyeglasses prior to their completion and delivery.

The prescription changes prior to completion and delivery of the eyeglasses.

The client dies prior to completion and delivery of the eyeglasses.

Reimbursement will not be made for the frames.

4.3.6.2Contact Lenses

Prior authorization is required for all contact lenses. The following procedure codes may be reimbursed for prosthetic and nonprosthetic contact lenses:

 

Procedure Codes

V2500

V2501

V2502

V2510

V2511

V2512

V2513

V2520

V2521

V2522

V2523

V2530

V2531

V2599

The following procedure codes may be reimbursed for the fitting or modification of a contact lens:

 

Procedure Codes

92310

92311

92312

92313

92314

92315

92316

92317

92325

92326

Contact Fitting for Corneal Bandage

A contact lens fitting for the placement of a corneal bandage lens may be medically necessary for eye protection and pain control due to a disease process or an injury. Procedure codes 92071 and 92072 may be reimbursed for the fitting of the corneal bandage for treatment and management.

Procedure code 92071 is limited to once per eye by any provider. Modifier LT or RT must be included on the claim to identify the eye on which the service was performed. When procedure code 92071 is performed on both eyes on the same date of service, one procedure may be reimbursed at the full rate and the second procedure may be reimbursed at half rate.

Procedure code 92072 is limited to one service per lifetime by the same provider.

Procedure code 92072 will be denied if billed on the same date of service by the same provider as procedure code 92071.

Prior Authorization Requirements

Nonprosthetic contact lenses and corneal plano bandage lenses must be prior authorized. The following documentation must be submitted with a request for nonprosthetic contact lenses and must be signed and dated by the prescribing physician or optometrist:

Diagnosis causing the refractive error (such as keratoconus)

Include the current and new prescriptions supporting a change of 0.5d or more in the sphere, cylinder, or prism measurements

Indicate which eyes to be treated

Specify the procedure codes requested

Include a brief statement addressing the medical necessity for vision correction by contact lens(es) and specify why eyeglasses are inappropriate or contraindicated for this client

For the contact fitting of the corneal bandage lens (procedure code 92071 or 92072), nonprosthetic contact lenses for nonemergency placement require prior authorization that must be obtained before the lenses are dispensed. Documentation submitted with the request must include the information listed above.

Nonprosthetic contact lenses for emergency placement do not require prior authorization. The emergency condition necessitating a corneal bandage must be documented on the claim.

Additional nonprosthetic contact lenses may be considered more frequently than the limitations outlined in this handbook when documentation in the client’s medical record supports medical necessity for a diopter change of 0.5d or more in the sphere, cylinder, prism measurements, or axis changes.

4.3.6.3Dispensing Requirements

Providers must be able to dispense standard size frames at no cost to the eligible client. The following criteria must be met for the dispensed frames:

Providers must offer each client who is 20 years of age or younger a choice of six styles in three colors for each type of frame: metal, zylonite, or combination of metal and zylonite.

Providers must offer each client who is 21 years of age or older a choice of three styles in three colors for each type of frame: metal, zylonite, or combination of metal and zylonite.

When a client chooses eyeglass or contact lens options that are beyond program limitations, the client must acknowledge their choice and his or her liability for the cost difference by signing the Vision Care Eyeglass Patient (Medicaid Client) Certification Form.

Dispensing of contact lenses include the fabrication, ordering, adjustment, dispensing, sale, and delivery to the client of the contact lenses prescribed by and dispensed in accordance with a prescription from a licensed physician or optometrist.

Dispensing of eyeglasses includes the design, verification, fitting, adjustment, sale, and delivery to the client of (1) fabricated and finished spectacle lenses, (2) frames, or (3) other ophthalmic devices, prescribed by and dispensed in accordance with a prescription from a licensed physician or optometrist.

4.3.6.4Repair

The eyeglass supplier is required to perform minor repairs on request (without charge) on eyeglasses that they have dispensed regardless of the client’s age. Minor repairs are those that cost $2 or less. The minor repairs are included in the reimbursement for the eyeglasses and are not reimbursed separately.

For clients who are birth through 20 years of age, repairs that cost $2 or more may be reimbursed using procedure code V2799. The following criteria apply:

The cost of repair supplies cannot exceed the cost of replacement eyeglasses.

All repair supplies must be new and at least equivalent to the original item.

The provider must maintain in the client’s medical record an itemized list of repairs and the replacement cost to determine whether criteria are met for repair.

For clients who are 21 years of age and older, repair of nonprosthetic eyeglasses or contact lenses is not a benefit when the actual cost of materials exceeds $2.

The provider must make the client’s medical record available for review upon request.

4.3.6.5Nonprosthetic Replacement

Clients who are birth through 20 years of age may obtain replacement nonprosthetic eyeglasses if the first pair is lost or destroyed. There are no limitations on the number of replacements a client who is birth through 20 years of age may receive. If the eyewear is lost or destroyed, the provider must have the client sign the Vision Care Eyeglass Patient (Medicaid Client) Certification Form. Claims for replacement lenses must be submitted with the RB modifier to ensure accurate processing. Prior autho­rization is not required for the replacement of nonprosthetic eyeglasses.

Replacement of eyeglasses or contact lenses is also allowed with a change in axis. A new prescription must have at least one of the following changes:

A change of 0.50 diopters or more in any corresponding meridian.

A cylinder axis change of at least 20 degrees for a cylinder power of 0.50-0.62 diopters.

A cylinder axis change of at least 15 degrees for a cylinder power of 0.75-0.87 diopters.

A cylinder axis change of at least 10 degrees for a cylinder power of 1.00-1.87 diopters.

A cylinder axis change of at least 5 degrees for a cylinder power of 2.00 diopters or greater.

Note:Replacement glasses will not be reimbursed for a cylinder power of 0.12-0.37 diopters with a change in axis.

Prior authorization is required for replacement of non-prosthetic contact lenses.

If the client is diagnosed with aphakia, procedure code 92326 may be reimbursed for the replacement of a contact lens.

4.3.6.6Medicare 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: Texas Medicaid Fee-for-Service Reimbursement” (Vol. 1, General Information) for more information about current coinsurance and deductible payment guidelines.

Important: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.

4.3.7Vision Services for Prosthetic Eyewear

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:

Eye examinations for aphakia (including congenital aphakia) and disease or injury to the eye may be reimbursed as often as is medically necessary.

One pair of permanent prosthetic eyeglasses or contact lenses is a benefit during a client’s lifetime.

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:Fitting services are included in the reimbursement for prosthetic eyeglasses or contact lenses.

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.

4.3.7.1Eyeglasses or Contact Lenses Following Cataract Surgery

Temporary eyeglasses or contact lenses after cataract surgery may be reimbursed when they are billed with the appropriate lens and frame procedure codes and diagnosis code Z961.

Temporary eyeglasses or contact lenses may be reimbursed for up to 4 months after surgery until the client is ready for conventional eyeglasses or contact lenses, when it is medically necessary. The date of surgery is used to determine the convalescence period for temporary eyeglasses or contact lenses. Temporary eyeglasses or contact lenses will be denied if they are dispensed more than 4 months after the date of surgery.

Temporary eyeglasses or contact lenses may be reimbursed as often as is medically necessary during the postsurgical convalescence period.

4.3.7.2Repair

The eyeglass supplier is required to perform minor repairs on request (without charge) on eyeglasses that they have dispensed regardless of the client’s age. Minor repairs are those that cost $2 or less. The minor repairs are included in the reimbursement for the eyeglasses and are not reimbursed separately.

Repairs that cost $2 or more may be reimbursed using procedure code V2799. The following criteria apply:

The cost of repair supplies cannot exceed the cost of replacement eyeglasses.

All repair supplies must be new and at least equivalent to the original item.

The provider must maintain in the client’s medical record an itemized list of repairs and the replacement cost to determine whether criteria are met for repair.

The provider must make the client’s medical record available for review upon request.

4.3.7.3Prosthetic Replacement

Replacement prosthetic eyeglasses or contact lenses may be reimbursed as often as is medically necessary if the replacement is due to loss, destruction, or a significant change in visual acuity.

Replacement of eyeglasses or contact lenses is also allowed with a change in axis. A new prescription must have at least one of the following changes:

A change of 0.50 diopters or more in any corresponding meridian.

A cylinder axis change of at least 20 degrees for a cylinder power of 0.50-0.62 diopters.

A cylinder axis change of at least 15 degrees for a cylinder power of 0.75-0.87 diopters.

A cylinder axis change of at least 10 degrees for a cylinder power of 1.00-1.87 diopters.

A cylinder axis change of at least 5 degrees for a cylinder power of 2.00 diopters or greater.

Note:Replacement glasses will not be reimbursed for a cylinder power of 0.12-0.37 diopters with a change in axis.

The appropriate eyeglass and frame or contact lens procedure codes must be billed with modifier RB to indicate replacement.

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 nonprosthetic eyewear.

4.3.7.4Intraocular Lens (IOL) and Additional Eyewear

Intraocular lenses are benefits of Texas Medicaid. If conventional eyewear is medically necessary in addition to the IOL, the IOL is considered the prosthetic device, and the eyewear and any replacements are considered nonprosthetic.

Refer to:  Subsection 9.2.46.4, “Intraocular Lens (IOL)” in the Medical and Nursing Specialists, Physi­cians, and Physician Assistants Handbook (Vol. 2, Provider Handbooks) for more information about IOL benefits.

Subsection 4.3.6, “Nonprosthetic Eyeglasses or Contact Lenses” in this handbook for more information about nonprosthetic eyewear.

4.3.7.5Artificial Eyes

For clients who are birth through 20 years of age, artificial eyes may be considered under CCP.

4.3.7.6Ultraviolet (U-V) Protection

Procedure code V2755 may be reimbursed for U-V protection when billed with one of the following diagnosis codes:

Diagnosis Codes

H2701

H2702

H2703

H27111

H27112

H27113

H27121

H27122

H27123

H27131

H27132

H27133

Q123

Z961

UV lens procedure code V2755 will be denied when billed with the same date of service by the same provider as polycarbonate lens procedure code V2784.

UV and polycarbonate lens procedure codes are subject to CMS NCCI relationships.

Refer to:  The CMS NCCI web page for the published correct coding guidelines and specific appli­cable code combinations.

4.3.8Surgical Vision Services

Refer to:  Subsection 9.2.38.20, “Fluocinolone Acetonide (Retisert)” in the Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook (Vol. 2, Provider Handbooks) for more information about fluocinolone acetonide benefits.

Subsection 9.2.46, “Ophthalmology” in the Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook (Vol. 2, Provider Handbooks) for more information about surgical vision services.

4.3.9Prior Authorization

Prior authorization is required for the following:

Orthoptic or pleoptic training beyond the maximum limits outlined in subsection 4.3.5.8, “Orthoptic or Pleoptic Training” in this handbook

The unlisted ultrasound procedure

All contact lenses, except corneal bandage lens(es) for emergency placement

A completed Special Medical Prior Authorization (SMPA) Request Form must be submitted by fax or mail to the Special Medical Prior Authorization department. The form must be signed and dated by a physician familiar with the client before requesting prior authorization. The completed Special Medical Prior Authorization (SMPA) Request Form must include the procedure codes and numerical quantities for services requested. The completed, signed, and dated Special Medical Prior Authorization (SMPA) Request Form must be maintained by the provider and the prescribing physician in the client’s medical record.

To avoid unnecessary denials, the physician must provide correct and complete information, including documentation for medical necessity of the vision service requested. The physician must maintain documentation of medical necessity in the client’s medical record. The requesting provider may be asked for additional information to clarify or complete a request for the vision service.

4.4Documentation Requirements

All services require documentation to support the medical necessity of the service rendered, including vision services. Vision services are subject to retrospective review and recoupment if documentation does not support the service billed.

The client must sign and date the Vision Care Eyeglass Patient (Medicaid Client) Certification Form, and the provider must retain it in the provider’s records.

When a client chooses an eyeglasses or contact lens option beyond the program limitations, or nonpros­thetic eyeglasses or contact lenses are replaced because of loss or destruction the client must acknowledge their choice and liability for the cost difference by signing the Vision Care Eyeglass Patient (Medicaid Client) Certification Form and retain it in the provider’s records.

The current and previous prescriptions must be documented in the client’s medical record.

The provider must make the client’s medical record available for review upon request by the following:

HHSC

Office of the Attorney General

TMHP

4.5Claims Filing and Reimbursement

4.5.1Claims Filing

Vision care service claims must be submitted to TMHP in an approved electronic format or on a CMS-1500 paper claim form. Providers may purchase CMS-1500 paper claim forms from the vendor of their choice. TMHP does not supply the forms. When completing a CMS-1500 paper claim form, all required information must be included on the claim, as information is not keyed from attachments. Superbills, or itemized statements, are not accepted as claim supplements.

When submitting the client’s old and new prescriptions to show an axis change or a diopter change of.5 or more, enter the new prescription in Block 24D, line 5, and the old prescription in Block 24D, line 6 of the CMS-1500 paper claim form.

Claims for eye examination services require a diagnosis. Claims for eye examinations that lack a diagnosis are listed as an incomplete claim on the Remittance and Status (R&S) report and must be resubmitted for payment consideration. Electronic claims that lack a diagnosis will be rejected. A letter with the reason for rejection and instructions for resubmission will be mailed the following business day.

When the eye exam limitation is exceeded for clients who are 20 years of age and younger, identify one of the following situations in Block 19 of the CMS-1500 paper claim form:

A school nurse, teacher, or parent requests the eye examination.

The eye examination is medically necessary.

4.5.2Reimbursement

Providers must reflect the highest level of specificity for vision related diagnosis on claims or other documentation. Professional services by an optometrist for contact lenses and prosthetic eyewear are reimbursed in accordance with 1 TAC, §§355.8001, 355.8081, and 355.8085.

FQHCs are paid an all-inclusive rate per visit for payable services in accordance with 1 TAC, §355.8261.

Suppliers of nonprosthetic lenses and frames are reimbursed the lesser of their billed amount or of the established maximum allowable fee in accordance with 1 TAC, §355.8001. See the OFL or the applicable fee schedule on the TMHP website at www.tmhp.com.

Refer to:  Subsection 2.2, “Fee-for-Service Reimbursement Methodology” in “Section 2: Texas Medicaid Fee-for-Service Reimbursement” (Vol. 1, General Information) for more infor­mation about reimbursement.

Vision Services on the TMHP website at www.tmhp.com for a claim form example.

The nonsurgical vision procedure codes included in this handbook may be subject to the CMS NCCI relationships.

Refer to:  The CMS website at www.cms.gov for more information about NCCI relationships.

Texas Medicaid implemented mandated rate reductions for certain services. The OFL and static fee schedules include a column titled “Adjusted Fee” to display the individual fees with all mandated percentage reductions applied. Additional information about rate changes is available on the TMHP website at www.tmhp.com/pages/topics/rates.aspx.

4.5.2.1NCCI and MUE Guidelines

The HCPCS and CPT codes included in the Texas Medicaid Provider Procedures Manual are subject to NCCI relationships, which supersede any exceptions to NCCI code relationships that may be noted in the manuals. Providers should refer to the CMS NCCI web page for correct coding guidelines and specific applicable code combinations.

In instances when Texas Medicaid limitations are more restrictive than NCCI MUE guidance, Texas Medicaid limitations prevail.

If applicable and consistent with CMS billing guidelines, procedure codes must be billed with modifier LT (left side) or RT (right side) to identify the eye on which the service was performed.

5 Claims Resources

Refer to the following sections and forms when filing claims:

Resource

Location

Acronym Dictionary

“Appendix D: Acronym Dictionary” (Vol. 1, General Information)

Automated Inquiry System (AIS)

Subsection A.10, “TMHP Telephone and Fax Communication” in “Appendix A: State, Federal, and TMHP Contact Information” (Vol. 1, General Information)

CMS-1500 Paper Claim Filing Instructions

Subsection 6.5, “CMS-1500 Paper Claim Filing Instructions” in “Section 6: Claims Filing” (Vol. 1, General Information)

State, federal, and TMHP contact information

“Appendix A: State, Federal, and TMHP Contact Information” (Vol. 1, General Information)

TMHP electronic claims submission information

Subsection 6.2, “TMHP Electronic Claims Submission” in “Section 6: Claims Filing” (Vol. 1, General Information)

TMHP Electronic Data Interchange (EDI) information

“Section 3: TMHP Electronic Data Interchange (EDI)” (Vol. 1, General Information)

6 Contact TMHP

The TMHP Contact Center at 1-800-925-9126 is available Monday through Friday from 7 a.m. to 7 p.m., Central Time.

7 Forms

The following linked forms can also be found on the Forms page of the Provider section of the TMHP website at www.tmhp.com:

Forms

Hearing Evaluation, Fitting, and Dispensing Report (Form 3503)

Physician’s Examination Report

Vision Care Eyeglass Patient (Medicaid Client) Certification Form

Vision Care Eyeglass Patient (Medicaid Client) Certification Form (Spanish)

8 Claim Form Examples

The following linked claim form examples can also be found on the Claim Form Examples page of the Provider section of the TMHP website at www.tmhp.com:

Claim Form Examples

Hearing Aid Assessments

Vision Services