This article has a correction. To view the correction, click here.
Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, pre-certification, referrals, and claims/encounter data filing may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the client's specific MCO for details.
Effective for dates of service on or after September 1, 2021, the following updates will be effective for Texas Medicaid Vision Services-Nonsurgical benefits.
Eye Examination and Refraction Testing
Procedure codes S0620 and S0621 will be denied if billed on the same date of service as procedure codes 92201, 92202, 92020, 92265, 92270, 92273, 92274, 92285, 92286, and 92287.
Procedure code 92014 will no longer be reimbursed to certified nurse midwife, registered nurse, or licensed midwife providers for services rendered in the office, inpatient hospital, or outpatient hospital setting.
Ophthalmic Ultrasound
The following diagnosis codes will be added to procedure code 76514:
Added Diagnosis Codes | |||||
---|---|---|---|---|---|
H1811 | H1812 | H1813 | H1820 | H18211 | H18212 |
H18213 | H18221 | H18222 | H18223 | H18231 | H18232 |
H18233 | H18461 | H18462 | H18463 | H1851 | H1852 |
H1853 | H1854 | H1855 | H1859 | H18601 | H18602 |
H18603 | H18611 | H18612 | H18613 | H18621 | H18622 |
H18623 | H21551 | H21552 | H21553 | H401410 | H401411 |
H401412 | H401413 | H401414 | H101420 | H401421 | H401422 |
H401423 | H401424 | H401430 | H401431 | H401432 | H401433 |
H401434 | H10151 | H40152 | H40153 | T86840 | T86841 |
Z947 |
The following diagnosis codes will no longer be reimbursed when submitted with procedure code 76514:
Diagnosis Codes | |||||
---|---|---|---|---|---|
H401190 | H401191 | H401192 | H401193 | H401194 | H401510 |
H401511 | H401512 | H401513 | H401514 | H401520 | H401521 |
H401522 | H401523 | H401524 | H401530 | H401531 | H410532 |
H401533 | H401534 | H402290 |
The current one per lifetime limitation for procedure code 76514 does not apply when submitted with diagnosis codes H1811, H1812, H1813, H18211, H18212, H18213, H18231, H18232, H18233, H1851, H21551, H21552, H21553, T86840, T86841, or Z947.
Procedure code 76519 and 92136 with the appropriate LT or RT modifier may be reimbursed one service per eye, per day, any provider, and two services per lifetime, any provider, any combination.
Ophthalmic biometry procedure codes 76519 and 92136 are duplicative tests and cannot be performed together.
Ophthalmic biometry may be repeated after 12 months if the patient decides to have the surgery later or the procedure is performed by a different provider. Requests for a second ophthalmic biometry in less than 12 months will not be payable without documentation of significant change in vision.
Gonioscopy
The following diagnosis codes will be added for procedure code 92020:
Added Diagnosis Codes | |||||
---|---|---|---|---|---|
H20011 | H20012 | H20013 | H20021 | H20022 | H20023 |
H20031 | H20032 | H20033 | H20041 | H20042 | H20043 |
H20051 | H20052 | H20053 | H2010 | H2011 | H2012 |
H2021 | H2022 | H2023 | H20811 | H20812 | H20813 |
H20821 | H20822 | H20823 | H209 | H2101 | H2102 |
H2103 | H211X1 | H211X2 | H211X3 | H21211 | H21212 |
H21213 | H21221 | H21222 | H21223 | H21231 | H21232 |
H21233 | H21241 | H21242 | H21243 | H21251 | H21252 |
H21253 | H21261 | H21262 | H21263 | H21271 | H21272 |
H21273 | H2129 | H21301 | H21302 | H51303 | H21311 |
H21312 | H21313 | H21321 | H21322 | H21323 | H21331 |
H21332 | H 21333 | H21341 | H21342 | H21343 | H21351 |
H21352 | H21353 | H2141 | H2142 | H2143 | H21501 |
H21502 | H21503 | H21511 | H21512 | H21513 | H21521 |
H21522 | H21523 | H21531 | H21532 | H21533 | H21541 |
H21542 | H21543 | H21551 | H21552 | H21553 | H21561 |
H21562 | H21563 | H2181 | H2182 | H22 | H31401 |
H31402 | H31403 | H31411 | H31412 | H31413 | H31421 |
H31422 | H31423 | H3411 | H3412 | H3413 | H348110 |
H348111 | H348112 | H348120 | H348121 | H348122 | H348130 |
H348131 | H348132 | H348310 | H348311 | H348312 | H348320 |
H348321 | H348322 | H348330 | 348331 | H348332 | H35031 |
H35032 | H35033 | H35051 | H35052 | H35053 | H3521 |
H3522 | H3523 | H3582 | H47231 | H47232 | H47233 |
H401410 | H401411 | H401412 | H401413 | H401414 | H401420 |
H401421 | H401422 | H401423 | H401424 | H401430 | H401431 |
H401432 | H401433 | H401434 | H40151 | H40152 | H40153 |
The following diagnosis codes will no longer be reimbursed for procedure code 92020:
Diagnosis Codes | |||||
---|---|---|---|---|---|
H401190 | H401191 | H401192 | h401193 | h401194 | h402290 |
Corneal Topography
The following provider types and places of service will be added for procedure code 92025:
- The professional component may be reimbursed to physician assistant, nurse practitioner, clinical nurse specialist, physician, optometrist, federally qualified health centers (FQHC), and optometric group providers in the inpatient and outpatient hospital setting.
Orthoptic or Pleoptic Training
Limitation for procedure code 92065 will be expanded from 2 to 12 services per lifetime. Prior authorization will no longer be required when more than 2 services are requested. Providers must document in the medical record a diagnosis and the reason for continuous treatment if the client attends multiple training sessions.
The following provider type and places of service will be added for procedure code 92065:
- Physician assistant, nurse practitioner, clinical nurse specialist, physician, optometrist, federally qualified health centers (FQHC), and optometric group providers in the inpatient and outpatient hospital setting.
Contact Fitting for Corneal Bandage Lens
Procedure codes 92071 or 90272 must be billed on the same date of service as one of the following procedure codes:
Procedure Codes | |||||
---|---|---|---|---|---|
V2511 | V2512 | V2513 | V2520 | V2521 | V2522 |
V2523 |
Procedure code 92071 will be limited to one service, per eye, per day, same vision procedure, any provider. Must be billed with modifier LT or RT to identify the eye on which the service was performed. When performed on both eyes for the same date of service, providers must report the code twice with LT and RT modifiers. One will be reimbursed at the full rate and the other at half rate.
Scanning Computerized Ophthalmic Diagnostic Imaging
Procedure code 92134 does not require prior authorization for the first two services performed in a calendar year. Providers may request additional services with prior authorization for a total of 12 services per calendar year.
Ophthalmoscopy, Extended Ophthalmoscopy and Fluorescein Angiography
Procedure codes 92201 and 92202 are limited to one service per day, any provider. The year limitation will be expanded to 12 services per calendar year, any provider. Updated criteria for medical necessity will be included in the Texas Medicaid Provider Procedures Manual, Vision and Hearing Services Handbook. Providers must keep supporting documentation in the client’s medical record when additional services are performed.
FQHC providers may be reimbursed for procedure codes 92227 and 92228 for services rendered in the office and outpatient hospital setting.
FQHC providers will no longer be reimbursed for procedure code 92230, 92235, 92240, 92242, 92250, and 92260 for services rendered in the inpatient hospital setting.
Procedure codes 92235 and 92240 will no longer have LT/RT modifier requirements and will be limited to one procedure per day, same procedure, any provider and two services per calendar year, same procedure, any provider.
Procedure code 92260 will no longer be diagnosis restricted.
Other Specialized Vision Services
The technical component for procedure code 92285 may be reimbursed to portable x-ray supplier, radiological or physiological lab providers in the office setting.
Polycarbonate Lenses
The following diagnosis codes will be added for procedure code V2784:
Diagnosis Codes | |||||
---|---|---|---|---|---|
E083521 | E083522 | E083523 | E083531 | E083532 | E083533 |
E083541 | E083542 | E083543 | E093521 | E093522 | E093523 |
E093531 | E093532 | E093533 | E09351 | E093542 | E093543 |
E103521 | E103522 | E103523 | E103531 | E103532 | E103533 |
E103541 | E103542 | E103543 | E113521 | E113522 | E113523 |
E113531 | E113532 | E113533 | E113541 | E113542 | E113543 |
E133521 | E133522 | E133523 | E133531 | E133532 | E133533 |
E133541 | E133542 | E133543 | F842 | G40011 | G40319 |
G40811 | G40812 | G40814 | G40821 | G40822 | G40823 |
G40824 | G713 | G721 | G803 | I69012 | I69112 |
I69212 | I69312 | I69812 | I69912 | P109 | P112 |
P119 | P529 | Q8782 | S061X0A | S061X1A | S061X2A |
S061X3A | S061X4A | S061X5A | S061X6A | S061X7A | S061X8A |
S061X9A | S06305A | S06305D | S06305S | S06306A | S06306D |
S06306S | S06307A | S06308A | S06371A | S06371D | S06371S |
S06372A | S06372D | S06372S | S06373A | S06373D | S06373S |
S06374A | S06374D | S06374S | S06357A | S06897A | S06898A |
S069X7A | S069X8A |
Eyeglasses or Contact Lenses
Procedure code V2221 will no longer be reimbursed to any provider type in the home setting.
Procedure codes V2410 and V2430 will be limited to one pair of non-prosthetic lenses per 24 calendar months, any provider.
Procedure code V2799 will no longer be reimbursed to any provider type in the home, independent laboratory, or birthing center setting.
Prior Authorization Requirements
Prior authorization is required for:
- Unlisted ultrasound procedures
- Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; retina, beyond the maximum limitation
- All contact lenses, except corneal bandage lenses for emergency placement
- All services requested through Texas Health Steps Comprehensive Care Program
Notes:
- All other vision services listed in the current Texas Medicaid Provider Procedures Manual, Vision and Hearing Services Handbook do not require prior authorization.
- All records are subject to retrospective review to ensure documentation supports the medical necessity of the requested services.
For more information, call the TMHP Contact Center at 800-925-9126.