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1T-A General Ophthalmological Services

Service Code
92004 (CPT) Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; comprehensive, new patient, 1 or more visits
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

General ophthalmological services include a medical examination and evaluation with the initiation or continuation of a diagnostic and treatment program. General ophthalmologic services include the following definitions for the two levels of service:

  • a. Intermediate ophthalmological services are an evaluation of a new or existing condition

complicated with a new diagnostic or management problem not necessarily relating to the primary diagnosis. This service is used for an acute condition or for a chronic condition which is stable.

  • b. Comprehensive ophthalmological services are a general evaluation of the complete visual

system. The comprehensive services constitute a single service entity but do not need to be performed at one session.

Limits

General ophthalmological services are not covered for any one of the following:

  • a. screening, preventative or refractive error services (routine eye exams);
  • b. prescription of lenses;
  • c. monitoring contact lenses for refractive error correction; or
  • d. follow-up of a condition that does not require diagnosis or treatment.

Length of Stay

Intermediate and comprehensive ophthalmological services for established

Exclusions

General ophthalmological services are integrated services in which medical decision making is not separate from the examining techniques used. The following service components are included as part of general ophthalmologic services and must not be billed separately:

  • 1. slit lamp examination;
  • 2. keratometry;
  • 3. ophthalmoscopy;
  • 4. retinoscopy;
  • 5. tonometry; and
  • 6. motor evaluation.

Intermediate and comprehensive ophthalmological services for established beneficiaries are each limited to 2 times per year.

Place of Service

Inpatient, Outpatient, Office

Additional Service Specifics

General ophthalmological services are comprised of integrated services and are billed with one unit per complete examination even if performed over more than one session.

How to Submit

N/A - No authorization is required

Resources

1T-A General Ophthalmological Services

Service Code
92012 (CPT) Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established patient
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

General ophthalmological services include a medical examination and evaluation with the initiation or continuation of a diagnostic and treatment program. General ophthalmologic services include the following definitions for the two levels of service:

  • a. Intermediate ophthalmological services are an evaluation of a new or existing condition

complicated with a new diagnostic or management problem not necessarily relating to the primary diagnosis. This service is used for an acute condition or for a chronic condition which is stable.

  • b. Comprehensive ophthalmological services are a general evaluation of the complete visual

system. The comprehensive services constitute a single service entity but do not need to be performed at one session.

Limits

General ophthalmological services are not covered for any one of the following:

  • a. screening, preventative or refractive error services (routine eye exams);
  • b. prescription of lenses;
  • c. monitoring contact lenses for refractive error correction; or
  • d. follow-up of a condition that does not require diagnosis or treatment.

Length of Stay

Intermediate and comprehensive ophthalmological services for established

Exclusions

General ophthalmological services are integrated services in which medical decision making is not separate from the examining techniques used. The following service components are included as part of general ophthalmologic services and must not be billed separately:

  • 1. slit lamp examination;
  • 2. keratometry;
  • 3. ophthalmoscopy;
  • 4. retinoscopy;
  • 5. tonometry; and
  • 6. motor evaluation.

Intermediate and comprehensive ophthalmological services for established beneficiaries are each limited to 2 times per year.

Place of Service

Inpatient, Outpatient, Office

Additional Service Specifics

General ophthalmological services are comprised of integrated services and are billed with one unit per complete examination even if performed over more than one session.

How to Submit

N/A - No authorization is required

Resources

1T-A General Ophthalmological Services

Service Code
92014 (CPT) Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive, established patient, 1 or more visits
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

General ophthalmological services include a medical examination and evaluation with the initiation or continuation of a diagnostic and treatment program. General ophthalmologic services include the following definitions for the two levels of service:

  • a. Intermediate ophthalmological services are an evaluation of a new or existing condition

complicated with a new diagnostic or management problem not necessarily relating to the primary diagnosis. This service is used for an acute condition or for a chronic condition which is stable.

  • b. Comprehensive ophthalmological services are a general evaluation of the complete visual

system. The comprehensive services constitute a single service entity but do not need to be performed at one session.

Limits

General ophthalmological services are not covered for any one of the following:

  • a. screening, preventative or refractive error services (routine eye exams);
  • b. prescription of lenses;
  • c. monitoring contact lenses for refractive error correction; or
  • d. follow-up of a condition that does not require diagnosis or treatment.

Length of Stay

Intermediate and comprehensive ophthalmological services for established

Exclusions

General ophthalmological services are integrated services in which medical decision making is not separate from the examining techniques used. The following service components are included as part of general ophthalmologic services and must not be billed separately:

  • 1. slit lamp examination;
  • 2. keratometry;
  • 3. ophthalmoscopy;
  • 4. retinoscopy;
  • 5. tonometry; and
  • 6. motor evaluation.

Intermediate and comprehensive ophthalmological services for established beneficiaries are each limited to 2 times per year.

Place of Service

Inpatient, Outpatient, Office

Additional Service Specifics

General ophthalmological services are comprised of integrated services and are billed with one unit per complete examination even if performed over more than one session.

How to Submit

N/A - No authorization is required

Resources

Computerized corneal topography, unilateral or bilateral, with interpretation and report

Service Code
92025 (CPT) Computerized corneal topography, unilateral or bilateral, with interpretation and report
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

1T-2, Special Ophthalmological Services

Service Code
92060 (CPT) Sensorimotor examination with multiple measurements of ocular deviation (eg, restrictive or paretic muscle with diplopia) with interpretation and report (separate procedure)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Special ophthalmological services are special evaluations of the visual system, which go beyond services included under general ophthalmological services. Interpretation and report by the physician is an integral part of special ophthalmological services where indicated. Special ophthalmological services include the following procedures:

Limits

Separate Procedures Special Ophthalmological Services include procedures and services that are designated as separate procedures. A separate procedure is one that is carried out as an integral component of a total service or procedure. The services or procedures designated as separate procedures must not be billed in addition to the total procedure or service of which it is considered an integral component. These services or procedures must be reported only when performed independently, unrelated or distinct from other procedures or services provided.Contact Lens Fitting for Treatment Fitting of contact lens for treatment of disease and for management of keratoconus is limited to four lenses per 365 days.

Scanning Computerized Ophthalmic Diagnostic Imaging

  • a. Pre-glaucoma beneficiary or a beneficiary with mild damage amay receive one SCODI per 365 days.
  • b. A Beneficiary with moderate damage may

receive up to two SCODIs per 365 days OR one SCODI and one visual field per 365 days if medically necessary. When both tests are performed, only one of each test is covered per 365 days.

Fundus Photography Fundus photography studies are limited to one per 365 days for detection and interpretation of diabetic retinopathy in a beneficiary with a diagnosis of diabetes mellitus.

Exclusions

Computerized Corneal Topography Medicaid shall not cover computerized corneal topography for any of the following:

  • a. routine follow-up testing;
  • b. repeat testing if not indicated by a change of vision as reported in connection

with one of the listed conditions in Subsection 3.2.3;

  • c. on the same date of service as keratoplasty; or
  • d. services performed for screening purposes.Sensorimotor Examination

Medicaid shall not cover a sensorimotor exam if there is not a complaint and the beneficiary’s condition is properly controlled. A repeat exam shall not be covered for any of the following:

  • a. when there is no change in the treatment plan;
  • b. no new symptoms are present; or
  • c. the previous result was reliable.Fitting of Therapeutic Contact Lens

Medicaid shall not cover fitting of therapeutic contact lens on the same date of surface as a cornea procedure.Scanning Computerized Ophthalmic Diagnostic Imaging Medicaid shall not cover SCODI for the following:

  • a. to further validate a diagnosis that has been confirmed through earlier

detection;

  • b. for a beneficiary with advanced glaucomatous damage; instead, visual fields

must be performed;

  • c. when performed as screening; or
  • d. SCODI of the optic nerve and SCODI of the retina are not covered on the

same date of service. Ophthalmic biometry Medicaid shall not cover ophthalmic biometry (Optical Coherence Biometry - OCB) by partial coherence interferometry on the same date of service as ophthalmic biometry by ultrasound echography, A-scan. Fundus Photography Medicaid shall not cover fundus photography for any of the following:

  • a. to screen or evaluate retinal conditions other than diabetic retinopathy;
  • b. when the final composite image captured does not include the entire Diabetic

Retinopathy Study seven-standard field area (DRS 7); or

  • c. when the final retinal images are graded using an automatic process only.

Place of Service

Inpatient, outpatient, office

How to Submit

N/A - No authorization is required

Resources

Orthoptic and/or pleoptic training, with continuing medical direction and evaluation

Service Code
92065 (CPT) Orthoptic and/or pleoptic training, with continuing medical direction and evaluation
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Prior approval (PA) is required prior to the start of all treatment services. The provider shall submit a request to the DHHS utilization review contractor to start the PA process. Detailed information and instructions for registering and submitting requests is available on the DHHS utilization review contractor's website: https://choicepa.medicaidprograms.org/Account/Login.aspx?ReturnUrl=%2f The PA request must clearly indicate that the service of a licensed therapist is required. For a beneficiary under age 21, the provider shall submit information supporting that all EPSDT criteria are met and evidence-based literature supporting the request, if available. A written evaluation report must be completed within three months of the requested treatment start date. When continued treatment is requested, an annual re-evaluation of the beneficiary’s status and performance must be documented in a written evaluation report. Each reauthorization request must document the efficacy of treatment. When granted, the approval is for medical approval only and does not guarantee payment or ensure beneficiary eligibility on the date of service. Retroactive PA is considered when Medicaid coverage is granted with a retroactive eligibility date after a beneficiary receives a service. Medicaid does not guarantee approval of retroactive PA requests.

Conditional Requirements

Pre-authorization required for all providers unless rendered on same day as evaluation.

Age Group Details

All

How to Submit

If applicable, please submit your request to Trillium.

Orthoptic and/or pleoptic training, with continuing medical direction and evaluation

Service Code
92065 (CPT) Orthoptic and/or pleoptic training, with continuing medical direction and evaluation
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
Medicaid Child (Age 0-20)
Diagnosis Group
Physical Health

Authorization Guidelines

The prior approval process is deemed met by the IEP, IFSP, IHP, BIP or 504 Plan processes.

Conditional Requirements

Pre-authorization required for all providers unless rendered on same day as evaluation.

How to Submit

If applicable, please submit your request to Trillium.

1T-2, Special Ophthalmological Services

Service Code
92071 (CPT) Fitting of contact lens for treatment of ocular surface disease
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Special ophthalmological services are special evaluations of the visual system, which go beyond services included under general ophthalmological services. Interpretation and report by the physician is an integral part of special ophthalmological services where indicated. Special ophthalmological services include the following procedures:

Limits

Separate Procedures Special Ophthalmological Services include procedures and services that are designated as separate procedures. A separate procedure is one that is carried out as an integral component of a total service or procedure. The services or procedures designated as separate procedures must not be billed in addition to the total procedure or service of which it is considered an integral component. These services or procedures must be reported only when performed independently, unrelated or distinct from other procedures or services provided.Contact Lens Fitting for Treatment Fitting of contact lens for treatment of disease and for management of keratoconus is limited to four lenses per 365 days.

Scanning Computerized Ophthalmic Diagnostic Imaging

  • a. Pre-glaucoma beneficiary or a beneficiary with mild damage amay receive one SCODI per 365 days.
  • b. A Beneficiary with moderate damage may

receive up to two SCODIs per 365 days OR one SCODI and one visual field per 365 days if medically necessary. When both tests are performed, only one of each test is covered per 365 days.

Fundus Photography Fundus photography studies are limited to one per 365 days for detection and interpretation of diabetic retinopathy in a beneficiary with a diagnosis of diabetes mellitus.

Exclusions

Computerized Corneal Topography Medicaid shall not cover computerized corneal topography for any of the following:

  • a. routine follow-up testing;
  • b. repeat testing if not indicated by a change of vision as reported in connection

with one of the listed conditions in Subsection 3.2.3;

  • c. on the same date of service as keratoplasty; or
  • d. services performed for screening purposes.Sensorimotor Examination

Medicaid shall not cover a sensorimotor exam if there is not a complaint and the beneficiary’s condition is properly controlled. A repeat exam shall not be covered for any of the following:

  • a. when there is no change in the treatment plan;
  • b. no new symptoms are present; or
  • c. the previous result was reliable.Fitting of Therapeutic Contact Lens

Medicaid shall not cover fitting of therapeutic contact lens on the same date of surface as a cornea procedure.Scanning Computerized Ophthalmic Diagnostic Imaging Medicaid shall not cover SCODI for the following:

  • a. to further validate a diagnosis that has been confirmed through earlier

detection;

  • b. for a beneficiary with advanced glaucomatous damage; instead, visual fields

must be performed;

  • c. when performed as screening; or
  • d. SCODI of the optic nerve and SCODI of the retina are not covered on the

same date of service. Ophthalmic biometry Medicaid shall not cover ophthalmic biometry (Optical Coherence Biometry - OCB) by partial coherence interferometry on the same date of service as ophthalmic biometry by ultrasound echography, A-scan. Fundus Photography Medicaid shall not cover fundus photography for any of the following:

  • a. to screen or evaluate retinal conditions other than diabetic retinopathy;
  • b. when the final composite image captured does not include the entire Diabetic

Retinopathy Study seven-standard field area (DRS 7); or

  • c. when the final retinal images are graded using an automatic process only.

Place of Service

Inpatient, outpatient, office

How to Submit

N/A - No authorization is required

Resources

1T-2, Special Ophthalmological Services

Service Code
92072 (CPT) Fitting of contact lens for management of keratoconus, initial fitting
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Special ophthalmological services are special evaluations of the visual system, which go beyond services included under general ophthalmological services. Interpretation and report by the physician is an integral part of special ophthalmological services where indicated. Special ophthalmological services include the following procedures:

Limits

Separate Procedures Special Ophthalmological Services include procedures and services that are designated as separate procedures. A separate procedure is one that is carried out as an integral component of a total service or procedure. The services or procedures designated as separate procedures must not be billed in addition to the total procedure or service of which it is considered an integral component. These services or procedures must be reported only when performed independently, unrelated or distinct from other procedures or services provided.Contact Lens Fitting for Treatment Fitting of contact lens for treatment of disease and for management of keratoconus is limited to four lenses per 365 days.

Scanning Computerized Ophthalmic Diagnostic Imaging

  • a. Pre-glaucoma beneficiary or a beneficiary with mild damage amay receive one SCODI per 365 days.
  • b. A Beneficiary with moderate damage may

receive up to two SCODIs per 365 days OR one SCODI and one visual field per 365 days if medically necessary. When both tests are performed, only one of each test is covered per 365 days.

Fundus Photography Fundus photography studies are limited to one per 365 days for detection and interpretation of diabetic retinopathy in a beneficiary with a diagnosis of diabetes mellitus.

Exclusions

Computerized Corneal Topography Medicaid shall not cover computerized corneal topography for any of the following:

  • a. routine follow-up testing;
  • b. repeat testing if not indicated by a change of vision as reported in connection

with one of the listed conditions in Subsection 3.2.3;

  • c. on the same date of service as keratoplasty; or
  • d. services performed for screening purposes.Sensorimotor Examination

Medicaid shall not cover a sensorimotor exam if there is not a complaint and the beneficiary’s condition is properly controlled. A repeat exam shall not be covered for any of the following:

  • a. when there is no change in the treatment plan;
  • b. no new symptoms are present; or
  • c. the previous result was reliable.Fitting of Therapeutic Contact Lens

Medicaid shall not cover fitting of therapeutic contact lens on the same date of surface as a cornea procedure.Scanning Computerized Ophthalmic Diagnostic Imaging Medicaid shall not cover SCODI for the following:

  • a. to further validate a diagnosis that has been confirmed through earlier

detection;

  • b. for a beneficiary with advanced glaucomatous damage; instead, visual fields

must be performed;

  • c. when performed as screening; or
  • d. SCODI of the optic nerve and SCODI of the retina are not covered on the

same date of service. Ophthalmic biometry Medicaid shall not cover ophthalmic biometry (Optical Coherence Biometry - OCB) by partial coherence interferometry on the same date of service as ophthalmic biometry by ultrasound echography, A-scan. Fundus Photography Medicaid shall not cover fundus photography for any of the following:

  • a. to screen or evaluate retinal conditions other than diabetic retinopathy;
  • b. when the final composite image captured does not include the entire Diabetic

Retinopathy Study seven-standard field area (DRS 7); or

  • c. when the final retinal images are graded using an automatic process only.

Place of Service

Inpatient, outpatient, office

How to Submit

N/A - No authorization is required

Resources

1T-2, Special Ophthalmological Services

Service Code
92132 (CPT) Scanning computerized ophthalmic diagnostic imaging, anterior segment, with interpretation and report, unilateral or bilateral
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Special ophthalmological services are special evaluations of the visual system, which go beyond services included under general ophthalmological services. Interpretation and report by the physician is an integral part of special ophthalmological services where indicated. Special ophthalmological services include the following procedures:

Limits

Separate Procedures Special Ophthalmological Services include procedures and services that are designated as separate procedures. A separate procedure is one that is carried out as an integral component of a total service or procedure. The services or procedures designated as separate procedures must not be billed in addition to the total procedure or service of which it is considered an integral component. These services or procedures must be reported only when performed independently, unrelated or distinct from other procedures or services provided.Contact Lens Fitting for Treatment Fitting of contact lens for treatment of disease and for management of keratoconus is limited to four lenses per 365 days.

Scanning Computerized Ophthalmic Diagnostic Imaging

  • a. Pre-glaucoma beneficiary or a beneficiary with mild damage amay receive one SCODI per 365 days.
  • b. A Beneficiary with moderate damage may

receive up to two SCODIs per 365 days OR one SCODI and one visual field per 365 days if medically necessary. When both tests are performed, only one of each test is covered per 365 days.

Fundus Photography Fundus photography studies are limited to one per 365 days for detection and interpretation of diabetic retinopathy in a beneficiary with a diagnosis of diabetes mellitus.

Exclusions

Computerized Corneal Topography Medicaid shall not cover computerized corneal topography for any of the following:

  • a. routine follow-up testing;
  • b. repeat testing if not indicated by a change of vision as reported in connection

with one of the listed conditions in Subsection 3.2.3;

  • c. on the same date of service as keratoplasty; or
  • d. services performed for screening purposes.Sensorimotor Examination

Medicaid shall not cover a sensorimotor exam if there is not a complaint and the beneficiary’s condition is properly controlled. A repeat exam shall not be covered for any of the following:

  • a. when there is no change in the treatment plan;
  • b. no new symptoms are present; or
  • c. the previous result was reliable.Fitting of Therapeutic Contact Lens

Medicaid shall not cover fitting of therapeutic contact lens on the same date of surface as a cornea procedure.Scanning Computerized Ophthalmic Diagnostic Imaging Medicaid shall not cover SCODI for the following:

  • a. to further validate a diagnosis that has been confirmed through earlier

detection;

  • b. for a beneficiary with advanced glaucomatous damage; instead, visual fields

must be performed;

  • c. when performed as screening; or
  • d. SCODI of the optic nerve and SCODI of the retina are not covered on the

same date of service. Ophthalmic biometry Medicaid shall not cover ophthalmic biometry (Optical Coherence Biometry - OCB) by partial coherence interferometry on the same date of service as ophthalmic biometry by ultrasound echography, A-scan. Fundus Photography Medicaid shall not cover fundus photography for any of the following:

  • a. to screen or evaluate retinal conditions other than diabetic retinopathy;
  • b. when the final composite image captured does not include the entire Diabetic

Retinopathy Study seven-standard field area (DRS 7); or

  • c. when the final retinal images are graded using an automatic process only.

Place of Service

Inpatient, outpatient, office

How to Submit

N/A - No authorization is required

Resources

1T-2, Special Ophthalmological Services

Service Code
92133 (CPT) Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; optic nerve
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Special ophthalmological services are special evaluations of the visual system, which go beyond services included under general ophthalmological services. Interpretation and report by the physician is an integral part of special ophthalmological services where indicated. Special ophthalmological services include the following procedures:

Limits

Separate Procedures Special Ophthalmological Services include procedures and services that are designated as separate procedures. A separate procedure is one that is carried out as an integral component of a total service or procedure. The services or procedures designated as separate procedures must not be billed in addition to the total procedure or service of which it is considered an integral component. These services or procedures must be reported only when performed independently, unrelated or distinct from other procedures or services provided.Contact Lens Fitting for Treatment Fitting of contact lens for treatment of disease and for management of keratoconus is limited to four lenses per 365 days.

Scanning Computerized Ophthalmic Diagnostic Imaging

  • a. Pre-glaucoma beneficiary or a beneficiary with mild damage amay receive one SCODI per 365 days.
  • b. A Beneficiary with moderate damage may

receive up to two SCODIs per 365 days OR one SCODI and one visual field per 365 days if medically necessary. When both tests are performed, only one of each test is covered per 365 days.

Fundus Photography Fundus photography studies are limited to one per 365 days for detection and interpretation of diabetic retinopathy in a beneficiary with a diagnosis of diabetes mellitus.

Exclusions

Computerized Corneal Topography Medicaid shall not cover computerized corneal topography for any of the following:

  • a. routine follow-up testing;
  • b. repeat testing if not indicated by a change of vision as reported in connection

with one of the listed conditions in Subsection 3.2.3;

  • c. on the same date of service as keratoplasty; or
  • d. services performed for screening purposes.Sensorimotor Examination

Medicaid shall not cover a sensorimotor exam if there is not a complaint and the beneficiary’s condition is properly controlled. A repeat exam shall not be covered for any of the following:

  • a. when there is no change in the treatment plan;
  • b. no new symptoms are present; or
  • c. the previous result was reliable.Fitting of Therapeutic Contact Lens

Medicaid shall not cover fitting of therapeutic contact lens on the same date of surface as a cornea procedure.Scanning Computerized Ophthalmic Diagnostic Imaging Medicaid shall not cover SCODI for the following:

  • a. to further validate a diagnosis that has been confirmed through earlier

detection;

  • b. for a beneficiary with advanced glaucomatous damage; instead, visual fields

must be performed;

  • c. when performed as screening; or
  • d. SCODI of the optic nerve and SCODI of the retina are not covered on the

same date of service. Ophthalmic biometry Medicaid shall not cover ophthalmic biometry (Optical Coherence Biometry - OCB) by partial coherence interferometry on the same date of service as ophthalmic biometry by ultrasound echography, A-scan. Fundus Photography Medicaid shall not cover fundus photography for any of the following:

  • a. to screen or evaluate retinal conditions other than diabetic retinopathy;
  • b. when the final composite image captured does not include the entire Diabetic

Retinopathy Study seven-standard field area (DRS 7); or

  • c. when the final retinal images are graded using an automatic process only.

Place of Service

Inpatient, outpatient, office

How to Submit

N/A - No authorization is required

Resources

1T-2, Special Ophthalmological Services

Service Code
92134 (CPT) Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; retina
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Special ophthalmological services are special evaluations of the visual system, which go beyond services included under general ophthalmological services. Interpretation and report by the physician is an integral part of special ophthalmological services where indicated. Special ophthalmological services include the following procedures:

Limits

Separate Procedures Special Ophthalmological Services include procedures and services that are designated as separate procedures. A separate procedure is one that is carried out as an integral component of a total service or procedure. The services or procedures designated as separate procedures must not be billed in addition to the total procedure or service of which it is considered an integral component. These services or procedures must be reported only when performed independently, unrelated or distinct from other procedures or services provided.Contact Lens Fitting for Treatment Fitting of contact lens for treatment of disease and for management of keratoconus is limited to four lenses per 365 days.

Scanning Computerized Ophthalmic Diagnostic Imaging

  • a. Pre-glaucoma beneficiary or a beneficiary with mild damage amay receive one SCODI per 365 days.
  • b. A Beneficiary with moderate damage may

receive up to two SCODIs per 365 days OR one SCODI and one visual field per 365 days if medically necessary. When both tests are performed, only one of each test is covered per 365 days.

Fundus Photography Fundus photography studies are limited to one per 365 days for detection and interpretation of diabetic retinopathy in a beneficiary with a diagnosis of diabetes mellitus.

Exclusions

Computerized Corneal Topography Medicaid shall not cover computerized corneal topography for any of the following:

  • a. routine follow-up testing;
  • b. repeat testing if not indicated by a change of vision as reported in connection

with one of the listed conditions in Subsection 3.2.3;

  • c. on the same date of service as keratoplasty; or
  • d. services performed for screening purposes.Sensorimotor Examination

Medicaid shall not cover a sensorimotor exam if there is not a complaint and the beneficiary’s condition is properly controlled. A repeat exam shall not be covered for any of the following:

  • a. when there is no change in the treatment plan;
  • b. no new symptoms are present; or
  • c. the previous result was reliable.Fitting of Therapeutic Contact Lens

Medicaid shall not cover fitting of therapeutic contact lens on the same date of surface as a cornea procedure.Scanning Computerized Ophthalmic Diagnostic Imaging Medicaid shall not cover SCODI for the following:

  • a. to further validate a diagnosis that has been confirmed through earlier

detection;

  • b. for a beneficiary with advanced glaucomatous damage; instead, visual fields

must be performed;

  • c. when performed as screening; or
  • d. SCODI of the optic nerve and SCODI of the retina are not covered on the

same date of service. Ophthalmic biometry Medicaid shall not cover ophthalmic biometry (Optical Coherence Biometry - OCB) by partial coherence interferometry on the same date of service as ophthalmic biometry by ultrasound echography, A-scan. Fundus Photography Medicaid shall not cover fundus photography for any of the following:

  • a. to screen or evaluate retinal conditions other than diabetic retinopathy;
  • b. when the final composite image captured does not include the entire Diabetic

Retinopathy Study seven-standard field area (DRS 7); or

  • c. when the final retinal images are graded using an automatic process only.

Place of Service

Inpatient, outpatient, office

How to Submit

N/A - No authorization is required

Resources

1T-2, Special Ophthalmological Services

Service Code
92136 (CPT) Ophthalmic biometry by partial coherence interferometry with intraocular lens power calculation
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Special ophthalmological services are special evaluations of the visual system, which go beyond services included under general ophthalmological services. Interpretation and report by the physician is an integral part of special ophthalmological services where indicated. Special ophthalmological services include the following procedures:

Limits

Separate Procedures Special Ophthalmological Services include procedures and services that are designated as separate procedures. A separate procedure is one that is carried out as an integral component of a total service or procedure. The services or procedures designated as separate procedures must not be billed in addition to the total procedure or service of which it is considered an integral component. These services or procedures must be reported only when performed independently, unrelated or distinct from other procedures or services provided.Contact Lens Fitting for Treatment Fitting of contact lens for treatment of disease and for management of keratoconus is limited to four lenses per 365 days.

Scanning Computerized Ophthalmic Diagnostic Imaging

  • a. Pre-glaucoma beneficiary or a beneficiary with mild damage amay receive one SCODI per 365 days.
  • b. A Beneficiary with moderate damage may

receive up to two SCODIs per 365 days OR one SCODI and one visual field per 365 days if medically necessary. When both tests are performed, only one of each test is covered per 365 days.

Fundus Photography Fundus photography studies are limited to one per 365 days for detection and interpretation of diabetic retinopathy in a beneficiary with a diagnosis of diabetes mellitus.

Exclusions

Computerized Corneal Topography Medicaid shall not cover computerized corneal topography for any of the following:

  • a. routine follow-up testing;
  • b. repeat testing if not indicated by a change of vision as reported in connection

with one of the listed conditions in Subsection 3.2.3;

  • c. on the same date of service as keratoplasty; or
  • d. services performed for screening purposes.Sensorimotor Examination

Medicaid shall not cover a sensorimotor exam if there is not a complaint and the beneficiary’s condition is properly controlled. A repeat exam shall not be covered for any of the following:

  • a. when there is no change in the treatment plan;
  • b. no new symptoms are present; or
  • c. the previous result was reliable.Fitting of Therapeutic Contact Lens

Medicaid shall not cover fitting of therapeutic contact lens on the same date of surface as a cornea procedure.Scanning Computerized Ophthalmic Diagnostic Imaging Medicaid shall not cover SCODI for the following:

  • a. to further validate a diagnosis that has been confirmed through earlier

detection;

  • b. for a beneficiary with advanced glaucomatous damage; instead, visual fields

must be performed;

  • c. when performed as screening; or
  • d. SCODI of the optic nerve and SCODI of the retina are not covered on the

same date of service. Ophthalmic biometry Medicaid shall not cover ophthalmic biometry (Optical Coherence Biometry - OCB) by partial coherence interferometry on the same date of service as ophthalmic biometry by ultrasound echography, A-scan. Fundus Photography Medicaid shall not cover fundus photography for any of the following:

  • a. to screen or evaluate retinal conditions other than diabetic retinopathy;
  • b. when the final composite image captured does not include the entire Diabetic

Retinopathy Study seven-standard field area (DRS 7); or

  • c. when the final retinal images are graded using an automatic process only.

Place of Service

Inpatient, outpatient, office

How to Submit

N/A - No authorization is required

Resources

1T-2, Special Ophthalmological Services

Service Code
92250 (CPT) Fundus photography with interpretation and report
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Special ophthalmological services are special evaluations of the visual system, which go beyond services included under general ophthalmological services. Interpretation and report by the physician is an integral part of special ophthalmological services where indicated. Special ophthalmological services include the following procedures:

Limits

Separate Procedures Special Ophthalmological Services include procedures and services that are designated as separate procedures. A separate procedure is one that is carried out as an integral component of a total service or procedure. The services or procedures designated as separate procedures must not be billed in addition to the total procedure or service of which it is considered an integral component. These services or procedures must be reported only when performed independently, unrelated or distinct from other procedures or services provided.Contact Lens Fitting for Treatment Fitting of contact lens for treatment of disease and for management of keratoconus is limited to four lenses per 365 days.

Scanning Computerized Ophthalmic Diagnostic Imaging

  • a. Pre-glaucoma beneficiary or a beneficiary with mild damage amay receive one SCODI per 365 days.
  • b. A Beneficiary with moderate damage may

receive up to two SCODIs per 365 days OR one SCODI and one visual field per 365 days if medically necessary. When both tests are performed, only one of each test is covered per 365 days.

Fundus Photography Fundus photography studies are limited to one per 365 days for detection and interpretation of diabetic retinopathy in a beneficiary with a diagnosis of diabetes mellitus.

Exclusions

Computerized Corneal Topography Medicaid shall not cover computerized corneal topography for any of the following:

  • a. routine follow-up testing;
  • b. repeat testing if not indicated by a change of vision as reported in connection

with one of the listed conditions in Subsection 3.2.3;

  • c. on the same date of service as keratoplasty; or
  • d. services performed for screening purposes.Sensorimotor Examination

Medicaid shall not cover a sensorimotor exam if there is not a complaint and the beneficiary’s condition is properly controlled. A repeat exam shall not be covered for any of the following:

  • a. when there is no change in the treatment plan;
  • b. no new symptoms are present; or
  • c. the previous result was reliable.Fitting of Therapeutic Contact Lens

Medicaid shall not cover fitting of therapeutic contact lens on the same date of surface as a cornea procedure.Scanning Computerized Ophthalmic Diagnostic Imaging Medicaid shall not cover SCODI for the following:

  • a. to further validate a diagnosis that has been confirmed through earlier

detection;

  • b. for a beneficiary with advanced glaucomatous damage; instead, visual fields

must be performed;

  • c. when performed as screening; or
  • d. SCODI of the optic nerve and SCODI of the retina are not covered on the

same date of service. Ophthalmic biometry Medicaid shall not cover ophthalmic biometry (Optical Coherence Biometry - OCB) by partial coherence interferometry on the same date of service as ophthalmic biometry by ultrasound echography, A-scan. Fundus Photography Medicaid shall not cover fundus photography for any of the following:

  • a. to screen or evaluate retinal conditions other than diabetic retinopathy;
  • b. when the final composite image captured does not include the entire Diabetic

Retinopathy Study seven-standard field area (DRS 7); or

  • c. when the final retinal images are graded using an automatic process only.

Place of Service

Inpatient, outpatient, office

How to Submit

N/A - No authorization is required

Resources

1T-2, Special Ophthalmological Services

Service Code
92265 (CPT) Needle oculoelectromyography, 1 or more extraocular muscles, 1 or both eyes, with interpretation and report
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Special ophthalmological services are special evaluations of the visual system, which go beyond services included under general ophthalmological services. Interpretation and report by the physician is an integral part of special ophthalmological services where indicated. Special ophthalmological services include the following procedures:

Limits

Separate Procedures Special Ophthalmological Services include procedures and services that are designated as separate procedures. A separate procedure is one that is carried out as an integral component of a total service or procedure. The services or procedures designated as separate procedures must not be billed in addition to the total procedure or service of which it is considered an integral component. These services or procedures must be reported only when performed independently, unrelated or distinct from other procedures or services provided.Contact Lens Fitting for Treatment Fitting of contact lens for treatment of disease and for management of keratoconus is limited to four lenses per 365 days.

Scanning Computerized Ophthalmic Diagnostic Imaging

  • a. Pre-glaucoma beneficiary or a beneficiary with mild damage amay receive one SCODI per 365 days.
  • b. A Beneficiary with moderate damage may

receive up to two SCODIs per 365 days OR one SCODI and one visual field per 365 days if medically necessary. When both tests are performed, only one of each test is covered per 365 days.

Fundus Photography Fundus photography studies are limited to one per 365 days for detection and interpretation of diabetic retinopathy in a beneficiary with a diagnosis of diabetes mellitus.

Exclusions

Computerized Corneal Topography Medicaid shall not cover computerized corneal topography for any of the following:

  • a. routine follow-up testing;
  • b. repeat testing if not indicated by a change of vision as reported in connection

with one of the listed conditions in Subsection 3.2.3;

  • c. on the same date of service as keratoplasty; or
  • d. services performed for screening purposes.Sensorimotor Examination

Medicaid shall not cover a sensorimotor exam if there is not a complaint and the beneficiary’s condition is properly controlled. A repeat exam shall not be covered for any of the following:

  • a. when there is no change in the treatment plan;
  • b. no new symptoms are present; or
  • c. the previous result was reliable.Fitting of Therapeutic Contact Lens

Medicaid shall not cover fitting of therapeutic contact lens on the same date of surface as a cornea procedure.Scanning Computerized Ophthalmic Diagnostic Imaging Medicaid shall not cover SCODI for the following:

  • a. to further validate a diagnosis that has been confirmed through earlier

detection;

  • b. for a beneficiary with advanced glaucomatous damage; instead, visual fields

must be performed;

  • c. when performed as screening; or
  • d. SCODI of the optic nerve and SCODI of the retina are not covered on the

same date of service. Ophthalmic biometry Medicaid shall not cover ophthalmic biometry (Optical Coherence Biometry - OCB) by partial coherence interferometry on the same date of service as ophthalmic biometry by ultrasound echography, A-scan. Fundus Photography Medicaid shall not cover fundus photography for any of the following:

  • a. to screen or evaluate retinal conditions other than diabetic retinopathy;
  • b. when the final composite image captured does not include the entire Diabetic

Retinopathy Study seven-standard field area (DRS 7); or

  • c. when the final retinal images are graded using an automatic process only.

Place of Service

Inpatient, outpatient, office

How to Submit

N/A - No authorization is required

Resources

1T-2, Special Ophthalmological Services

Service Code
92270 (CPT) Electro-oculography with interpretation and report
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Special ophthalmological services are special evaluations of the visual system, which go beyond services included under general ophthalmological services. Interpretation and report by the physician is an integral part of special ophthalmological services where indicated. Special ophthalmological services include the following procedures:

Limits

Separate Procedures Special Ophthalmological Services include procedures and services that are designated as separate procedures. A separate procedure is one that is carried out as an integral component of a total service or procedure. The services or procedures designated as separate procedures must not be billed in addition to the total procedure or service of which it is considered an integral component. These services or procedures must be reported only when performed independently, unrelated or distinct from other procedures or services provided.Contact Lens Fitting for Treatment Fitting of contact lens for treatment of disease and for management of keratoconus is limited to four lenses per 365 days.

Scanning Computerized Ophthalmic Diagnostic Imaging

  • a. Pre-glaucoma beneficiary or a beneficiary with mild damage amay receive one SCODI per 365 days.
  • b. A Beneficiary with moderate damage may

receive up to two SCODIs per 365 days OR one SCODI and one visual field per 365 days if medically necessary. When both tests are performed, only one of each test is covered per 365 days.

Fundus Photography Fundus photography studies are limited to one per 365 days for detection and interpretation of diabetic retinopathy in a beneficiary with a diagnosis of diabetes mellitus.

Exclusions

Computerized Corneal Topography Medicaid shall not cover computerized corneal topography for any of the following:

  • a. routine follow-up testing;
  • b. repeat testing if not indicated by a change of vision as reported in connection

with one of the listed conditions in Subsection 3.2.3;

  • c. on the same date of service as keratoplasty; or
  • d. services performed for screening purposes.Sensorimotor Examination

Medicaid shall not cover a sensorimotor exam if there is not a complaint and the beneficiary’s condition is properly controlled. A repeat exam shall not be covered for any of the following:

  • a. when there is no change in the treatment plan;
  • b. no new symptoms are present; or
  • c. the previous result was reliable.Fitting of Therapeutic Contact Lens

Medicaid shall not cover fitting of therapeutic contact lens on the same date of surface as a cornea procedure.Scanning Computerized Ophthalmic Diagnostic Imaging Medicaid shall not cover SCODI for the following:

  • a. to further validate a diagnosis that has been confirmed through earlier

detection;

  • b. for a beneficiary with advanced glaucomatous damage; instead, visual fields

must be performed;

  • c. when performed as screening; or
  • d. SCODI of the optic nerve and SCODI of the retina are not covered on the

same date of service. Ophthalmic biometry Medicaid shall not cover ophthalmic biometry (Optical Coherence Biometry - OCB) by partial coherence interferometry on the same date of service as ophthalmic biometry by ultrasound echography, A-scan. Fundus Photography Medicaid shall not cover fundus photography for any of the following:

  • a. to screen or evaluate retinal conditions other than diabetic retinopathy;
  • b. when the final composite image captured does not include the entire Diabetic

Retinopathy Study seven-standard field area (DRS 7); or

  • c. when the final retinal images are graded using an automatic process only.

Place of Service

Inpatient, outpatient, office

How to Submit

N/A - No authorization is required

Resources

1T-2, Special Ophthalmological Services

Service Code
92273 (CPT) Electroretinography (ERG), with interpretation and report; full field (ie, ffERG, flash ERG, Ganzfeld ERG)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Special ophthalmological services are special evaluations of the visual system, which go beyond services included under general ophthalmological services. Interpretation and report by the physician is an integral part of special ophthalmological services where indicated. Special ophthalmological services include the following procedures:

Limits

Separate Procedures Special Ophthalmological Services include procedures and services that are designated as separate procedures. A separate procedure is one that is carried out as an integral component of a total service or procedure. The services or procedures designated as separate procedures must not be billed in addition to the total procedure or service of which it is considered an integral component. These services or procedures must be reported only when performed independently, unrelated or distinct from other procedures or services provided.Contact Lens Fitting for Treatment Fitting of contact lens for treatment of disease and for management of keratoconus is limited to four lenses per 365 days.

Scanning Computerized Ophthalmic Diagnostic Imaging

  • a. Pre-glaucoma beneficiary or a beneficiary with mild damage amay receive one SCODI per 365 days.
  • b. A Beneficiary with moderate damage may

receive up to two SCODIs per 365 days OR one SCODI and one visual field per 365 days if medically necessary. When both tests are performed, only one of each test is covered per 365 days.

Fundus Photography Fundus photography studies are limited to one per 365 days for detection and interpretation of diabetic retinopathy in a beneficiary with a diagnosis of diabetes mellitus.

Exclusions

Computerized Corneal Topography Medicaid shall not cover computerized corneal topography for any of the following:

  • a. routine follow-up testing;
  • b. repeat testing if not indicated by a change of vision as reported in connection

with one of the listed conditions in Subsection 3.2.3;

  • c. on the same date of service as keratoplasty; or
  • d. services performed for screening purposes.Sensorimotor Examination

Medicaid shall not cover a sensorimotor exam if there is not a complaint and the beneficiary’s condition is properly controlled. A repeat exam shall not be covered for any of the following:

  • a. when there is no change in the treatment plan;
  • b. no new symptoms are present; or
  • c. the previous result was reliable.Fitting of Therapeutic Contact Lens

Medicaid shall not cover fitting of therapeutic contact lens on the same date of surface as a cornea procedure.Scanning Computerized Ophthalmic Diagnostic Imaging Medicaid shall not cover SCODI for the following:

  • a. to further validate a diagnosis that has been confirmed through earlier

detection;

  • b. for a beneficiary with advanced glaucomatous damage; instead, visual fields

must be performed;

  • c. when performed as screening; or
  • d. SCODI of the optic nerve and SCODI of the retina are not covered on the

same date of service. Ophthalmic biometry Medicaid shall not cover ophthalmic biometry (Optical Coherence Biometry - OCB) by partial coherence interferometry on the same date of service as ophthalmic biometry by ultrasound echography, A-scan. Fundus Photography Medicaid shall not cover fundus photography for any of the following:

  • a. to screen or evaluate retinal conditions other than diabetic retinopathy;
  • b. when the final composite image captured does not include the entire Diabetic

Retinopathy Study seven-standard field area (DRS 7); or

  • c. when the final retinal images are graded using an automatic process only.

Place of Service

Inpatient, outpatient, office

How to Submit

N/A - No authorization is required

Resources

1T-2, Special Ophthalmological Services

Service Code
92274 (CPT) Electroretinography (ERG), with interpretation and report; multifocal (mfERG)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Special ophthalmological services are special evaluations of the visual system, which go beyond services included under general ophthalmological services. Interpretation and report by the physician is an integral part of special ophthalmological services where indicated. Special ophthalmological services include the following procedures:

Limits

Separate Procedures Special Ophthalmological Services include procedures and services that are designated as separate procedures. A separate procedure is one that is carried out as an integral component of a total service or procedure. The services or procedures designated as separate procedures must not be billed in addition to the total procedure or service of which it is considered an integral component. These services or procedures must be reported only when performed independently, unrelated or distinct from other procedures or services provided.Contact Lens Fitting for Treatment Fitting of contact lens for treatment of disease and for management of keratoconus is limited to four lenses per 365 days.

Scanning Computerized Ophthalmic Diagnostic Imaging

  • a. Pre-glaucoma beneficiary or a beneficiary with mild damage amay receive one SCODI per 365 days.
  • b. A Beneficiary with moderate damage may

receive up to two SCODIs per 365 days OR one SCODI and one visual field per 365 days if medically necessary. When both tests are performed, only one of each test is covered per 365 days.

Fundus Photography Fundus photography studies are limited to one per 365 days for detection and interpretation of diabetic retinopathy in a beneficiary with a diagnosis of diabetes mellitus.

Exclusions

Computerized Corneal Topography Medicaid shall not cover computerized corneal topography for any of the following:

  • a. routine follow-up testing;
  • b. repeat testing if not indicated by a change of vision as reported in connection

with one of the listed conditions in Subsection 3.2.3;

  • c. on the same date of service as keratoplasty; or
  • d. services performed for screening purposes.Sensorimotor Examination

Medicaid shall not cover a sensorimotor exam if there is not a complaint and the beneficiary’s condition is properly controlled. A repeat exam shall not be covered for any of the following:

  • a. when there is no change in the treatment plan;
  • b. no new symptoms are present; or
  • c. the previous result was reliable.Fitting of Therapeutic Contact Lens

Medicaid shall not cover fitting of therapeutic contact lens on the same date of surface as a cornea procedure.Scanning Computerized Ophthalmic Diagnostic Imaging Medicaid shall not cover SCODI for the following:

  • a. to further validate a diagnosis that has been confirmed through earlier

detection;

  • b. for a beneficiary with advanced glaucomatous damage; instead, visual fields

must be performed;

  • c. when performed as screening; or
  • d. SCODI of the optic nerve and SCODI of the retina are not covered on the

same date of service. Ophthalmic biometry Medicaid shall not cover ophthalmic biometry (Optical Coherence Biometry - OCB) by partial coherence interferometry on the same date of service as ophthalmic biometry by ultrasound echography, A-scan. Fundus Photography Medicaid shall not cover fundus photography for any of the following:

  • a. to screen or evaluate retinal conditions other than diabetic retinopathy;
  • b. when the final composite image captured does not include the entire Diabetic

Retinopathy Study seven-standard field area (DRS 7); or

  • c. when the final retinal images are graded using an automatic process only.

Place of Service

Inpatient, outpatient, office

How to Submit

N/A - No authorization is required

Resources

1T-2, Special Ophthalmological Services

Service Code
92283 (CPT) Color vision examination, extended, eg, anomaloscope or equivalent
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Special ophthalmological services are special evaluations of the visual system, which go beyond services included under general ophthalmological services. Interpretation and report by the physician is an integral part of special ophthalmological services where indicated. Special ophthalmological services include the following procedures:

Limits

Separate Procedures Special Ophthalmological Services include procedures and services that are designated as separate procedures. A separate procedure is one that is carried out as an integral component of a total service or procedure. The services or procedures designated as separate procedures must not be billed in addition to the total procedure or service of which it is considered an integral component. These services or procedures must be reported only when performed independently, unrelated or distinct from other procedures or services provided.Contact Lens Fitting for Treatment Fitting of contact lens for treatment of disease and for management of keratoconus is limited to four lenses per 365 days.

Scanning Computerized Ophthalmic Diagnostic Imaging

  • a. Pre-glaucoma beneficiary or a beneficiary with mild damage amay receive one SCODI per 365 days.
  • b. A Beneficiary with moderate damage may

receive up to two SCODIs per 365 days OR one SCODI and one visual field per 365 days if medically necessary. When both tests are performed, only one of each test is covered per 365 days.

Fundus Photography Fundus photography studies are limited to one per 365 days for detection and interpretation of diabetic retinopathy in a beneficiary with a diagnosis of diabetes mellitus.

Exclusions

Computerized Corneal Topography Medicaid shall not cover computerized corneal topography for any of the following:

  • a. routine follow-up testing;
  • b. repeat testing if not indicated by a change of vision as reported in connection

with one of the listed conditions in Subsection 3.2.3;

  • c. on the same date of service as keratoplasty; or
  • d. services performed for screening purposes.Sensorimotor Examination

Medicaid shall not cover a sensorimotor exam if there is not a complaint and the beneficiary’s condition is properly controlled. A repeat exam shall not be covered for any of the following:

  • a. when there is no change in the treatment plan;
  • b. no new symptoms are present; or
  • c. the previous result was reliable.Fitting of Therapeutic Contact Lens

Medicaid shall not cover fitting of therapeutic contact lens on the same date of surface as a cornea procedure.Scanning Computerized Ophthalmic Diagnostic Imaging Medicaid shall not cover SCODI for the following:

  • a. to further validate a diagnosis that has been confirmed through earlier

detection;

  • b. for a beneficiary with advanced glaucomatous damage; instead, visual fields

must be performed;

  • c. when performed as screening; or
  • d. SCODI of the optic nerve and SCODI of the retina are not covered on the

same date of service. Ophthalmic biometry Medicaid shall not cover ophthalmic biometry (Optical Coherence Biometry - OCB) by partial coherence interferometry on the same date of service as ophthalmic biometry by ultrasound echography, A-scan. Fundus Photography Medicaid shall not cover fundus photography for any of the following:

  • a. to screen or evaluate retinal conditions other than diabetic retinopathy;
  • b. when the final composite image captured does not include the entire Diabetic

Retinopathy Study seven-standard field area (DRS 7); or

  • c. when the final retinal images are graded using an automatic process only.

Place of Service

Inpatient, outpatient, office

How to Submit

N/A - No authorization is required

Resources

1T-2, Special Ophthalmological Services

Service Code
92284 (CPT) Dark adaptation examination with interpretation and report
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Special ophthalmological services are special evaluations of the visual system, which go beyond services included under general ophthalmological services. Interpretation and report by the physician is an integral part of special ophthalmological services where indicated. Special ophthalmological services include the following procedures:

Limits

Separate Procedures Special Ophthalmological Services include procedures and services that are designated as separate procedures. A separate procedure is one that is carried out as an integral component of a total service or procedure. The services or procedures designated as separate procedures must not be billed in addition to the total procedure or service of which it is considered an integral component. These services or procedures must be reported only when performed independently, unrelated or distinct from other procedures or services provided.Contact Lens Fitting for Treatment Fitting of contact lens for treatment of disease and for management of keratoconus is limited to four lenses per 365 days.

Scanning Computerized Ophthalmic Diagnostic Imaging

  • a. Pre-glaucoma beneficiary or a beneficiary with mild damage amay receive one SCODI per 365 days.
  • b. A Beneficiary with moderate damage may

receive up to two SCODIs per 365 days OR one SCODI and one visual field per 365 days if medically necessary. When both tests are performed, only one of each test is covered per 365 days.

Fundus Photography Fundus photography studies are limited to one per 365 days for detection and interpretation of diabetic retinopathy in a beneficiary with a diagnosis of diabetes mellitus.

Exclusions

Computerized Corneal Topography Medicaid shall not cover computerized corneal topography for any of the following:

  • a. routine follow-up testing;
  • b. repeat testing if not indicated by a change of vision as reported in connection

with one of the listed conditions in Subsection 3.2.3;

  • c. on the same date of service as keratoplasty; or
  • d. services performed for screening purposes.Sensorimotor Examination

Medicaid shall not cover a sensorimotor exam if there is not a complaint and the beneficiary’s condition is properly controlled. A repeat exam shall not be covered for any of the following:

  • a. when there is no change in the treatment plan;
  • b. no new symptoms are present; or
  • c. the previous result was reliable.Fitting of Therapeutic Contact Lens

Medicaid shall not cover fitting of therapeutic contact lens on the same date of surface as a cornea procedure.Scanning Computerized Ophthalmic Diagnostic Imaging Medicaid shall not cover SCODI for the following:

  • a. to further validate a diagnosis that has been confirmed through earlier

detection;

  • b. for a beneficiary with advanced glaucomatous damage; instead, visual fields

must be performed;

  • c. when performed as screening; or
  • d. SCODI of the optic nerve and SCODI of the retina are not covered on the

same date of service. Ophthalmic biometry Medicaid shall not cover ophthalmic biometry (Optical Coherence Biometry - OCB) by partial coherence interferometry on the same date of service as ophthalmic biometry by ultrasound echography, A-scan. Fundus Photography Medicaid shall not cover fundus photography for any of the following:

  • a. to screen or evaluate retinal conditions other than diabetic retinopathy;
  • b. when the final composite image captured does not include the entire Diabetic

Retinopathy Study seven-standard field area (DRS 7); or

  • c. when the final retinal images are graded using an automatic process only.

Place of Service

Inpatient, outpatient, office

How to Submit

N/A - No authorization is required

Resources