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Vision Services
HP Provider Relations
October 2010
Agenda
– Objectives
– Vision Billing and Coverage
– Routine Examinations
– CPT®/HCPCS and Code Sets
– Medicare Bypass Table
– Frames and Lenses
– Replacement Eyeglasses
– Billing Members
– Written Correspondence
– Prior Authorization
– ANSI version 5010
– Common Denials
– Q&A
CPT copyright 2009 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
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Vision Services
October 2010
Objectives
– To provide a comprehensive overview of
IHCP policy regarding vision services
– To explain billing and coverage
guidelines for vision services
– To inform providers when it is
appropriate to bill members for
noncovered vision services
– To review the most common denial
codes for vision claims
– To answer questions that may arise
throughout the presentation
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Reference Material
– Ophthalmological Services are outlined in the IHCP Provider Manual,
Chapter 8
– 405 IAC 5-23 (Indiana Administrative Code)
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Understand
Billing procedures
Coverage and Billing Procedures
– The IHCP provides reimbursement
for ophthalmology services, subject
to the following restrictions:
• One routine vision care examination and
refraction for members 18 years old and
younger, per rolling 12-month period
• One routine vision care examination and
refraction for members 19 years old and
older, per rolling 24-month period
• Routine vision examinations may be
performed more often than the 12- and 24month periods described above if they are
billed with a medical diagnosis
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Routine Examinations – Common Codes
– Procedure codes (not an all-inclusive list)
• 92002, 92004, 92012, 92014
• 99201-99215
• 99241-99245
• 99251-99255
– Diagnosis codes
• V41, V410, V411
• V72, V720, V80, V801, V802
• V367X
– The routine examination limitations will apply when these procedure
codes are billed with these diagnosis codes
• Error code 6610 – routine vision exam limited to one per 12 months, age 1-18
• Error code 6611 – routine vision exam limited to one per 24 months, over age 18
CPT copyright 2009 American Medical Association. All rights reserved. CPT is a registered trademark of the American
Medical Association.
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Vision Services
October 2010
Routine Vision vs. Medical Examinations
– The diagnosis code related to the
specific procedure code should only
reflect the conditions treated on that
date of service
– Example: a patient is seen for eye
pain (379.91), but has a history of
hypermetropia/far sightedness
(367.0)
– If hypermetropia is not evaluated or
treated during the current visit, use
only diagnosis code 379.91
– If diagnosis code 367.0 is included
on the claim, the claim will be
considered a routine exam subject
to the limitations
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Routine Vision vs. Medical Examinations
– When a patient is seen for both a
medical and routine vision service
on the same date, the primary
reason for the encounter should be
used to determine whether the
service falls under the routine or
medical benefit
– If the primary reason for the visit
was eye pain, but a routine vision
exam and refraction were
performed:
• The exam should be coded with the eye
pain (medical) diagnosis, and the refraction
should be coded with the routine diagnosis
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Coverage and Billing Procedures
– Providers must use the appropriate Current Procedural
Terminology (CPT®) or Healthcare Common Procedure Coding
System (HCPCS) codes when submitting claims for vision
services
– Optometrists and opticians are subject to vision service code
sets, which are available at http://provider.indianamedicaid.com
– Many vision procedure codes are on the Medicare bypass table
• Claims for "dually eligibles" do not have to be billed to Medicare first
• Exams/services (92002, 92004, 92012, 92014, 92015, 92065, 92315, 92316)
• Frames (V2020, V2025); lenses (V2100-V2615)
– All claims must reflect a date of service, which is the date the
specific services were actually supplied, dispensed, or rendered
to the patient
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October 2010
Vision Services and Package B
– Generally, a routine eye exam and refraction would not be
related to the pregnancy, a complication thereof, or a
condition that if left untreated would lead to a higher level of
care
– However, if the member’s primary medical provider (PMP)
has specifically referred the member for evaluation of a
condition that may affect the pregnancy, the service would be
covered under Package B
• Examples:
 Diabetes with retinopathy
 Severe eye infection
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Lenses
– The IHCP only reimburses for tints
1 and 2
• V2745 U1 – Tint, plastic, rose 1 or 2, per
lens
• V2745 U2 - Tint, glass, rose 1 or 2, per
lens
– The IHCP covers safety lenses only
for corneal lacerations and other
severe intractable ocular or ocular
adnexal disease
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Lenses – Noncovered
– The IHCP does not cover the following:
• V2702 – Deluxe lens feature
• V2744 – Tint, photochromic
• V2750 – Antireflective coating
• V2760 – Scratch resistant coating
• V2781 – Progressive lenses
• V2782 – Lens, index 1.54-1.65 plastic, or 1.60 to 1.79 glass
• V2783 – Lens, index >= 1.66 plastic, or >= 1.80 glass
• V2786 – Specialty multi-focal lens
– If a member chooses to upgrade to one of these codes
• Provider bills the IHCP for the basic lens code
• Provider may bill the member for the upgrade portion as long as
noncoverage is explained and a waiver is signed
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Lenses
– Polycarbonate lenses
• Are covered only for medically necessary conditions that require additional
ocular protection
• Examples of medical necessity
− Member has carcinoma in one eye, and the healthy eye requires corrective
lens
− Member has eye surgery and still requires corrective lens
• Patient charts must support medical necessity
– Contact lenses
• Are covered when medically necessary
• Examples of medical necessity
− Severe facial deformity
− Severe allergies to all frame materials
• Providers can bill codes 92310 through 92326, in addition to general
ophthalmology services
• Patient charts must support medical necessity
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Frames
– The IHCP reimburses for frames including, but not limited to,
plastic or metal
• Procedure code V2020
– Deluxe or fancy frames are covered only when medically
necessary
• Procedure code V2025
• Submit documentation outlining medical necessity with claim
 Examples
• Facial deformity
• Allergic reaction to standard frame material
• Provision of special sized frames for an infant
• Submit an invoice with the claim; reimbursement is 90% of retail price
– If the member chooses to upgrade to a deluxe frame, the entire
frame is noncovered, and the member can be billed
• Member must sign a waiver prior to service being rendered
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Replacement Eyeglasses
– Members who have met medical necessity guidelines for replacement
eyeglasses are eligible for a new pair of eyeglasses
• Younger than 19 years of age: eligible one year from date IHCP provided their original
or replacement eyeglasses
• 19 years of age and older: eligible two years from date IHCP provided their original or
replacement eyeglasses
– The member must meet the following medical necessity guidelines in
at least one eye for the provision of eyeglasses, including
replacements
• A change of 0.75 diopters for patients 6 to 42 years old
• A change of 0.50 diopters for patients more than 42 years old
• An axis change of at least 15 degrees
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Modifiers for Replacement Eyeglasses
– Replacement eyeglasses due to loss,
theft, or damage beyond repair, prior to
the frequency guidelines, should be
billed with modifier RP or U8
– Replacement eyeglasses due to
change in prescription, prior to the
frequency guidelines, should be billed
with modifier SC
– Use of either modifier indicates
appropriate documentation is on file in
the patient’s record to substantiate the
need
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Billing Members
Providers may bill IHCP members for services exceeding the
benefit limitations under the following circumstances:
– If the Eligibility Verification System (EVS) shows that a limitation
has been met:
• Inform the member the service will be noncovered and they will be billed
• Have the member sign a waiver
– If EVS does not show that benefits have been exhausted:
• Provider may ask the member or guardian to attest in writing that they have not
received the service within the past one or two years (depending on age)
• Inform the member if they are misrepresenting, and the claim is denied, the
member will be responsible for the charges
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Written Correspondence
– Providers may send an inquiry to the
HP Written Correspondence Unit to
determine whether a member has
exceeded service limitations
HP Provider Written Correspondence
P.O. Box 7263
Indianapolis, IN 46207-7263
– Allow 10 business days for a
response
• Responses are mailed to the "pay to" address
– Use IHCP Inquiry Form
• Available at www.indianamedicaid.com
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EVS – Benefit Limits Reached
– The Benefit Limits Reached information on vision services
contained in the Eligibility Verification System may not always
be up to date on members covered by the Hoosier Healthwise,
risk-based managed care program
– Providers should contact the managed care entity (MCE) vision
plan to inquire about vision services benefit limits
– If the MCE’s vision plan is not able to provide information on
vision benefit limits reached, the provider may obtain an
attestation waiver from the member
• The member attests he/she is eligible for the exam/eye wear, and if they are
mis-informing they understand they will be liable
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Business Practice to Restrict Services
– Providers may establish a business practice to refuse or restrict
certain services that are provided to the general public
– The provider must establish a written policy in order to do so
– If a provider intends to provide exams, diagnostic services,
surgical services, but will not provide eyewear, the member
must be advised at the time the appointment is made that the
provider does not provide “IHCP approved glasses"
– A prescription may be provided for the member to have filled at
a participating eyewear provider, or the member may choose to
find another provider that will furnish both services
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Prior Authorization
– For Traditional Medicaid, prior
authorization is not required for vision
care services except for the following
provisions:
• Blepharoplasty for a significant obstructive
vision problem
• Prosthetic device, except eyeglasses
• Reconstruction or plastic surgery
– Risk-based managed care MCEs
may have additional prior
authorization requirements
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October 2010
HIPAA 5010
– The mandatory compliance date for
ANSI version 5010 and the National
Council for Prescription Drug
Programs (NCPDP) version D.0 for all
covered entities is January 1, 2012
– If submitting claims to the IHCP, you
need to prepare for these upgrades to
prevent delay in payment
– The IHCP and HP will test
transactions on a scheduled basis
– Specific transaction testing dates will
be provided at a future date
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HIPAA 5010
– Transactions affected by this upgrade:
• Institutional claims (837I)
• Dental claims (837D)
• Medical claims (837P)
• Pharmacy claims (NCPDP)
• Eligibility verifications (270/271)
• Claim status inquiry (276/277)
• Electronic remittance advices (835)
• Prior authorizations (278)
• Managed Care enrollment (834)
• Capitation payments (820)
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Testing Information
– All Trading Partners currently approved to submit 4010A1 and
NCPDP 5.1 versions will be required to be approved for 5010
and D.0 transaction compliance
• All software products used to submit 4010 and NCPDP 5.1 versions must be
tested and approved for 5010 and D.0
– Testing will begin January 2011 and include:
• Clearinghouses, billing services, software vendors, individual providers,
provider groups
– Providers that exchange data with the IHCP using an IHCPapproved software vendor will not need to test
– Each trading partner will be required to submit a
new Trading Partner Agreement
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What You Need To Do
– If you bill IHCP directly
• Begin the process to upgrade to the ANSI 5010 or NCPDP D.0 versions
– If you are using a billing service or clearinghouse
• Find out if they are preparing for the HIPAA upgrades to ANSI v5010 and
NCPDP vD.0
• IHCP Companion Guides will be available during the fourth quarter of 2010
– Questions should be directed to [email protected]
OR
– Call the EDI Solutions Service Desk
• 1-877-877-5182 or (317) 488-5160
– Watch for additional information on the testing process, revised
IHCP Companion Guides, and the schedule for transaction
testing on this mandated initiative in bulletins, banner pages,
and newsletters at www.indianamedicaid.com
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Deny
Most common denials
Edit 0593 – Medicare Denied Detail
– Cause
• Medicare has denied at least one detail line on the claim
– Resolution
• Denied detail lines must be rebilled on a separate claim form
• Do not submit claim as a crossover
• Include the Medicare Remittance Notice (MRN) with the claim with the reason
for the denial
• Remember: Many vision codes are on the Medicare bypass table and do not
need to be billed to Medicare
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October 2010
Edit 4021 – Procedure Code vs. Program
Indicator
– Cause
• Procedure code billed is restricted to a specific program
− Package B, C, E
− 590 Program
– Resolution
• Verify eligibility prior to rendering service
• Submit claim with appropriate procedure code
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Edit 268 – Billed Amount Missing
– Cause
• The billed amount is missing from one of the detail lines
• The billed amount is missing from field 28 of CMS-1500 claim form
– Resolution
• Verify each detail line has a billed amount
• Enter the total billed amount in field 28
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Edit 5001 – Exact Duplicate
– Cause
• Claim is an exact duplicate of a claim in the history file or another claim being
processed in the same cycle
– Resolution
• Research prior claims for a paid status
 Web interChange
 HP Customer Service Center
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Edit 2017 – Recipient Ineligible on DOS Due
to Enrollment in Managed Care Entity
– Cause
• The member was not eligible for traditional Medicaid on the date of service
because they were enrolled in the risk-based managed care (RBMC) program
– Resolution
• Verify eligibility prior to rendering service to see if the member is in RBMC
• Bill the appropriate MCE (managed care entity)
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Q&A