You must have JavaScript enabled in order to access this part of the site. Please enable JavaScript and then reload this page in order to continue.

WARNING: THIS IS A TEXAS HEALTH AND HUMAN SERVICES INFORMATION RESOURCES SYSTEM THAT CONTAINS STATE AND/OR U.S. GOVERNMENT INFORMATION. BY USING THIS SYSTEM YOU ACKNOWLEDGE AND AGREE THAT YOU HAVE NO RIGHT OF PRIVACY IN CONNECTION WITH YOUR USE OF THE SYSTEM OR YOUR ACCESS TO THE INFORMATION CONTAINED WITHIN IT. BY ACCESSING AND USING THIS SYSTEM YOU ARE CONSENTING TO THE MONITORING OF YOUR USE OF THE SYSTEM, AND TO SECURITY ASSESSMENT AND AUDITING ACTIVITIES THAT MAY BE USED FOR LAW ENFORCEMENT OR OTHER LEGALLY PERMISSIBLE PURPOSES. ANY UNAUTHORIZED USE OR ACCESS, OR ANY UNAUTHORIZED ATTEMPTS TO USE OR ACCESS, THIS SYSTEM MAY SUBJECT YOU TO DISCIPLINARY ACTION, SANCTIONS, CIVIL PENALTIES, OR CRIMINAL PROSECUTION TO THE EXTENT PERMITTED UNDER APPLICABLE LAW.
-----------------------
AMA/ADA End User License Agreement
LICENSE FOR USE OF CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION ("CPT® ")

You, your employees and agents are authorized to use CPT only as contained in materials on the Texas Medicaid & Healthcare Partnership (TMHP) website solely for your own personal use in directly participating in healthcare programs administered by THHS. You acknowledge that AMA holds all copyright, trademark and other rights in CPT.

Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. License to use CPT for any use not authorized herein must be obtained through the American Medical Association, Intellectual Property Services, 515 N. State Street, Chicago, Illinois, 60610. Applications are available at the American Medical Association website, www.ama-assn.org/go/cpt.

U.S. Government Rights

This product includes CPT which is commercial technical data and/or computer databases and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer databases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2) (November 1995) and/or subject to the restrictions of DFARS 227.7202-1(a) (June 1995) and DFARS 227.7202-3(a) (June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department of Defense Federal procurements.

Disclaimer of Warranties and Liabilities

CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to the implied warranties of merchantability and fitness for a particular purpose. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the American Medical Association (AMA) is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this product is with THHS, and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this product.

This Agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this Agreement.

Should the for egoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by clicking below on the button labeled "accept".

THE LICENSE GRANTED HEREIN IS EXPRESSLY CONTINUED UPON YOUR ACCEPTANCE OF ALL TERMS AND CONDITIONS CONTAINED IN THIS AGREEMENT. BY CLICKING BELOW ON THE BUTTON LABELED "ACCEPT", YOU HEREBY ACKNOWLEDGE THAT YOU HAVE READ, UNDERSTOOD, AND AGREED TO ALL TERMS AND CONDITIONS SET FORTH IN THIS AGREEMENT.

IF YOU DO NO AGREE WITH ALL TERMS AND CONDITIONS SET FORTH HEREIN, CLICK BELOW ON THE BUTTON LABELED "DO NOT ACCEPT" AND EXIT FROM THIS COMPUTER SCREEN.

IF YOU ARE ACTING ON BEHALF OF AN ORGANIZATION, YOU REPRESENT THAT YOU ARE AUTHORIZED TO ACT ON BEHALF OF SUCH ORGANIZATION AND THAT YOUR ACCEPTANCE OF THE TERMS OF THIS AGREEMENT CREATES A LEGALLY ENFORCEABLE OBLIGATION OF THE ORGANIZATION. AS USED HEREIN, "YOU" AND "YOUR" REFER TO YOU AND ANY ORGANIZATION ON BEHALF OF WHICH YOU ARE ACTING.

1. Subject to the terms and conditions contained in this Agreement, you, your employees and agents are authorized to use CDT only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. Use of CDT is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. You acknowledge that the ADA holds all copyright, trademark and other rights in CDT. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights included in the materials.

2. Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CDT for resale and/or license, transferring copies of CDT to any party not bound by this agreement, creating any modified or derivative work of CDT, or making any commercial use of CDT. License to use CDT for any use not authorized herein must be obtained through the American Dental Association, 211 East Chicago Avenue, Chicago IL 60611. Applications are available at the American Dental Association web site, http://www.ADA.org.

3. U.S. GOVERNMENT RIGHTS. Applicable Federal Acquisition Regulation Clauses (FARS)\Department of Defense Federal Acquisition Regulation Supplement (DFARS) Restrictions Apply to Government Use. This product includes CDT, which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable, which was developed exclusively at private expense by the American Dental Association, 211 East Chicago Avenue, Chicago Illinois, 60611. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2) (June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a) (June 1995) and DFARS 227.7202-3(a) (June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department of Defense Federal Procurements.

4. ADA DISCLAIMER OF WARRANTIES AND LIABILITIES. CDT is provided “as is” without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. No fee schedules, basic unit, relative values or related listings are included in CDT. The ADA does no t directly or indirectly practice medicine or dispense dental services. The sole responsibility for the software, including any CDT and other content contained therein, is with TMHP or the CMS; and no endorsement by the ADA is intended or implied. The ADA expressly disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice to you if you violate the terms of the Agreement. The ADA is a third party beneficiary to this Agreement.

5. CMS DISCLAIMER. The scope of this license is determined by the ADA, the copyright holder. Any questions pertaining to the license or use of the CDT should be addressed to the ADA. End Users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CDT. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL COVERED BY THIS LICENSE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

The license granted herein is expressly conditioned upon your acceptance of all terms and conditions contained in this agreement. If the foregoing terms and conditions are acceptable to you, please indicate your agreement by clicking below on the button labeled "ACCEPT". If you do not agree to the terms and conditions, you may not access or use the software. Instead, you must exit from this computer screen.

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

Last updated on 8/3/2021

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.