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Vision Services-Nonsurgical Benefits to Change Effective September 1, 2021

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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.