Source: http://www.tmhp.com/Manuals_HTML1/TMPPM/Archive/2017/TMPPM/2_Vision_and_Hearing_Srvs/2_Vision_and_Hearing_Srvs.htm
Timestamp: 2018-11-19 00:37:00
Document Index: 59914773

Matched Legal Cases: ['§371', '§355', '§355', '§354', '§355', '§355', '§355']

2_Vision_and_Hearing_Srvs
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.
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).
2 Nonimplantable Hearing Aid Devices and Related Services
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).
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.
Note:A SHARS Texas Provider Identifier (TPI) cannot be used to bill for these services.
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.
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
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:
The following additional procedure codes may be benefits for audiometric testing:
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:
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
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.
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:
•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.
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.
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.
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 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:
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
•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 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.
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.
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:
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:
Texas Medicaid may reimburse hearing aid fitters and dispensers for the following services:
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 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
•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.
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.
2.4.1Claims Filing
Subsection 1.6.9, “Billing Clients” in “Section 1: Provider Enrollment and Responsibilities” (Vol. 1, General Information).
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.
•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.
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).
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.
Providers may refer to the OFL or the applicable fee schedule on the TMHP website at www.tmhp.com.
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.
3 Implantable Hearing Devices and Related Services
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.
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:
•The fitting of the device
•The reassessment to determine whether the device allows for adequate hearing
3.2.1Cochlear Implants
The following procedure codes may be reimbursed for the cochlear implant device, separate compo­nents, and services:
The following procedure codes may be reimbursed for diagnostic analysis of the cochlear implant:
3.2.1.1Prior Authorization
•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
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).
•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.
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
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.
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:
L8621 (Zink air non-rechargeable)
Maximum of 50 per month
L8622 (Alkaline non-rechargeable)
Maximum of 31 per month
L8623 (Lithium ion rechargeable)
2 batteries per calendar year
L8624 (Lithium ion rechargeable)
L7368 (Battery recharger unit for lithium ion rechargeable batteries)
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:
L92626
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:
L92640
3.2.2.1Prior Authorization
The following implantable hearing devices and services require prior authorization:
•ABI surgery, device, and replacement parts
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.
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:
3.2.3.1Prior Authorization
•BAHA implant surgery, device, and replacement parts
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:
•Sensorineural hearing loss
•Other anomalies of external ear with impairment of hearing
•Anomalies of skull and face bones
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.
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.
3.4.1Claims Filing
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.
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.
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.
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.
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).
•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:
Medical evaluation and examination may be reimbursed using the following procedure codes:
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
•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.
Refer to: The CMS NCCI web page for the published correct coding guidelines and specific appli­cable code combinations.
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.
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 irregularities
•Corneal disease
•Corneal injury
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:
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:
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:
•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:
92100*
*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 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:
92225*
92226*
92230*
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:
•Neoplasms of the retina
•Choroid (benign or malignant)
•Choroid disturbances
•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:
92227*
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
•Brain trauma
•Motor ataxia
•Marfan’s syndrome
•Ocular prostheses
•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)
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
•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.
4.3.6.2Contact Lenses
•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
4.3.6.3Dispensing Requirements
•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.
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
Repairs that cost $2 or more may be reimbursed using procedure code V2799. The following criteria apply:
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.
• A cylinder axis change of at least 20 degrees for a cylinder power of 0.50-0.62 diopters.
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:
H27123
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.
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
•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
•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.
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.
4.5.2.1NCCI and MUE Guidelines
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:
6 Contact TMHP
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