Vision Services Vision Services & & Vision Therapy - - PowerPoint PPT Presentation

Vision Services Vision Services & & Vision Therapy Vision Therapy

February 2, 2007 February 2, 2007

Who Can Provide Vision Who Can Provide Vision Services? Services?

• A licensed ophthalmologist,

A licensed ophthalmologist,

• ptometrist or optician may provide
• ptometrist or optician may provide

vision services. vision services.

Covered Covered Vision Services Vision Services

• The following services are covered for

The following services are covered for

clients clients under under the age of 21 the age of 21:

:

– – Eye Examinations (92002, 92004, 92012 Eye Examinations (92002, 92004, 92012 & 92014) & 92014) – – Eyeglasses (V2020 Eyeglasses (V2020-

• V2499)

V2499) – – Contact Lenses (V5200 Contact Lenses (V5200-

• V5231)

V5231)

Eye Examinations Eye Examinations

(92002, 92004, 92012, 92014) (92002, 92004, 92012, 92014)

• Eye exams should determine visual acuity

Eye exams should determine visual acuity and refraction, binocular vision and eye and refraction, binocular vision and eye health. health.

– – Special ophthalmologic services should be Special ophthalmologic services should be performed only when medically necessary. performed only when medically necessary. (92015 (92015-

• 92140)

92140) – – Eye care provider records must reflect medical Eye care provider records must reflect medical necessity and include interpretation and report, necessity and include interpretation and report, as appropriate, of the procedure. as appropriate, of the procedure.

• Office exams as medically necessary for the

Office exams as medically necessary for the treatment of eye disease or eye injury. treatment of eye disease or eye injury.

Eyeglasses Eyeglasses

(V2020 (V2020-

• V2499)

V2499)

• One pair of eyeglasses is covered

One pair of eyeglasses is covered within a 12 within a 12-

• month period.

month period.

– – Replacement of eyeglasses Replacement of eyeglasses – – Repair of eyeglasses Repair of eyeglasses – – Documentation of medically necessity Documentation of medically necessity

Eyeglasses Cont. Eyeglasses Cont.

(V2020 (V2020-

• V2499)

V2499)

– – EqualityCare allows up to $76.00 for standard EqualityCare allows up to $76.00 for standard frames.

• frames. The provider may not

The provider may not “ “balance bill balance bill” ” the client for glasses that cost more than the client for glasses that cost more than the allowable amount unless there is a the allowable amount unless there is a written agreement signed by the client written agreement signed by the client and the provider. and the provider.

• For example: When the client selects $120 frames and

For example: When the client selects $120 frames and EqualityCare allows up to $76, then the optometrist EqualityCare allows up to $76, then the optometrist should either mutually agree in writing with the client should either mutually agree in writing with the client that the client is responsible for the additional payment that the client is responsible for the additional payment

• f the frames ($44) or the provider may bill
• f the frames ($44) or the provider may bill

EqualityCare for $120 and accept the payment of $76 EqualityCare for $120 and accept the payment of $76 as payment in full for the frames. as payment in full for the frames.

Eyeglasses Cont. Eyeglasses Cont.

(V2020 (V2020-

• V2499)

V2499)

• Single vision, bifocal or trifocal lenses

Single vision, bifocal or trifocal lenses are covered. are covered.

– – Miscellaneous services (V2700 Miscellaneous services (V2700-

• V2799) are

V2799) are covered only with prior authorization (PA) covered only with prior authorization (PA) and when deemed medically necessary by and when deemed medically necessary by an ophthalmologist or optometrist. an ophthalmologist or optometrist. Exception: V2784 does not require PA Exception: V2784 does not require PA

Eyeglasses Cont. Eyeglasses Cont.

(V2020 (V2020-

• V2499)

V2499)

• Polycarbonate lenses (V2784) includes

Polycarbonate lenses (V2784) includes scratch resistant coating and are a covered scratch resistant coating and are a covered

• service. The procedure code must be billed
• service. The procedure code must be billed

as an add as an add-

• on to a standard C
• n to a standard C-
• 39 lens.

39 lens.

• Reimbursement for dispensing of frames,

Reimbursement for dispensing of frames, frame parts and/or lenses is not allowed in frame parts and/or lenses is not allowed in addition to reimbursement for dispensing of addition to reimbursement for dispensing of total eyeglasses. total eyeglasses.

• Providers must use the order date as the

Providers must use the order date as the date of dispensing. date of dispensing.

Contact Lenses Contact Lenses

(V5200 (V5200-

• V5231)

V5231)

• Contact lenses are covered for correction of

Contact lenses are covered for correction of pathological conditions when useful vision pathological conditions when useful vision cannot be obtained with regular lenses. cannot be obtained with regular lenses.

• Prior authorization is not required at the

Prior authorization is not required at the time of service; however, the medical record time of service; however, the medical record should document the client should document the client’ ’s need for s need for contact lenses versus eyeglasses. contact lenses versus eyeglasses.

Covered Services Covered Services

• The following services are covered for

The following services are covered for

clients clients over

• ver the age of 21

the age of 21:

:

– – Eye Examinations (92002, 92004, 92012 & Eye Examinations (92002, 92004, 92012 & 92014) 92014) – – Treatment of eye disease or eye injury. Treatment of eye disease or eye injury. – – Payment of deductible and/or coinsurance due Payment of deductible and/or coinsurance due

• n Medicare crossover claims for post surgical
• n Medicare crossover claims for post surgical

contact lenses and/or eyeglasses. contact lenses and/or eyeglasses.

Vision Therapy Vision Therapy

(92065) (92065)

• Vision therapy is a sequence of activities

Vision therapy is a sequence of activities individually prescribed and monitored by the individually prescribed and monitored by the doctor to develop efficient visual skills and doctor to develop efficient visual skills and processing. processing.

• Research has demonstrated vision therapy

Research has demonstrated vision therapy can be an effective treatment option for can be an effective treatment option for individuals under the age of 21 or individuals under the age of 21 or individuals with Acquired Brain Injury (ABI). individuals with Acquired Brain Injury (ABI).

Vision Therapy Vision Therapy

(92065) (92065)

• Vision therapy is administered in the

Vision therapy is administered in the

• ffice under the guidance of a
• ffice under the guidance of a

practitioner and requires a number of practitioner and requires a number of

• ffice visits depending on the severity
• ffice visits depending on the severity
• f the diagnosis conditions.
• f the diagnosis conditions.

Vision Therapy Vision Therapy

(92065) (92065)

• Research has demonstrated vision therapy can be an

Research has demonstrated vision therapy can be an effective treatment option for: effective treatment option for:

– – Ocular motility dysfunctions (eye movement disorders) Ocular motility dysfunctions (eye movement disorders) – – Non Non-

• strabismic

strabismic binocular disorders (inefficient eye binocular disorders (inefficient eye teaming) teaming) – – Strabismus (misalignment of the eyes) Strabismus (misalignment of the eyes) – – Amblyopia (poorly developing vision) Amblyopia (poorly developing vision) – – Accommodative disorders (focusing problems) Accommodative disorders (focusing problems) – – Visual information processing disorders, including visual Visual information processing disorders, including visual-

• motor integration and integration with other sensory

motor integration and integration with other sensory modalities. modalities.

Prior authorization is not required. Prior authorization is not required.

Training Aids Training Aids

(99070) (99070)

• Vision therapy training aids will be

Vision therapy training aids will be reimbursed at cost of invoice. Please reimbursed at cost of invoice. Please submit invoice with statement of submit invoice with statement of medical necessity using CPT code medical necessity using CPT code 99070. 99070.

Vision Therapy Vision Therapy

Coding for clients Coding for clients under under the age of 21: the age of 21:

• Vision therapy visits are capped at 32 per

Vision therapy visits are capped at 32 per 365 days for treatment of ICD 365 days for treatment of ICD-

• 9 diagnosis.

9 diagnosis.

• Additional visits or exceptions to these

Additional visits or exceptions to these diagnosis codes will be considered on a diagnosis codes will be considered on a case case-

• by

by-

• case basis only.

case basis only.

• In addition to the referenced ICD

In addition to the referenced ICD-

• 9 codes,

9 codes, vision therapy services performed in vision therapy services performed in-

• office
• ffice

are reported with CPT code 92065. are reported with CPT code 92065.

Vision Therapy Coding Vision Therapy Coding

Diagnosis Codes Diagnosis Codes Description Description

Amblyopia (limited to age 15 and under) Amblyopia (limited to age 15 and under) 368.01 368.01 Strabismic amblyopia Strabismic amblyopia 368.02 368.02 Deprivation amblyopia Deprivation amblyopia 368.03 368.03 Refractive amblyopia Refractive amblyopia Strabismus (Concomitant) Strabismus (Concomitant) 378.01 378.01 Monocular esotropia Monocular esotropia 378.05 378.05 Alternating esotropia Alternating esotropia 378.11 378.11 Monocular exotropia Monocular exotropia 378.15 378.15 Alternating exotropia Alternating exotropia 378.21 378.21 I ntermittent esotropia, monocular I ntermittent esotropia, monocular 378.22 378.22 I ntermittent esotropia, alternating I ntermittent esotropia, alternating 378.23 378.23 I ntermittent exotropia, monocular I ntermittent exotropia, monocular 378.24 378.24 I ntermittent exotropia, alternating I ntermittent exotropia, alternating 378.35 378.35 Accommodative component in esotropia Accommodative component in esotropia

Vision Therapy Coding Vision Therapy Coding

Diagnosis Codes Diagnosis Codes Description Description

Non Non-

• strabismic

strabismic disorder of binocular eye movements disorder of binocular eye movements 378.83 378.83 378.84 378.84 378.85 378.85 Ocular Motor Dysfunction Ocular Motor Dysfunction 379.57 379.57 379.58 379.58 Heterophoria Heterophoria 378.41 378.41 378.42 378.42 General Binocular Vision Disorder General Binocular Vision Disorder 368.30 368.30 Accommodative Disorder Accommodative Disorder 367.5 367.5 Nystagmus Nystagmus 379.51 379.51 Convergence insufficiency Convergence insufficiency Convergence excess Convergence excess Anomalies of divergence Anomalies of divergence Deficiencies of saccadic eye movements Deficiencies of saccadic eye movements Deficiencies of smooth pursuit movements Deficiencies of smooth pursuit movements Esophoria Esophoria Exophoria Exophoria General Binocular Vision Disorder General Binocular Vision Disorder Accommodative Disorder Accommodative Disorder Nystagmus Nystagmus

Vision Therapy Vision Therapy

Coding for clients Coding for clients over

• ver the age of 21:

the age of 21:

The following diagnosis codes are considered The following diagnosis codes are considered appropriate for adult clients eligible for appropriate for adult clients eligible for EqualityCare services under the Acquired Brain EqualityCare services under the Acquired Brain Injury (ABI) Waiver program: Injury (ABI) Waiver program:

• Vision Therapy for individuals receiving services

Vision Therapy for individuals receiving services under the ABI Program with qualifying medical under the ABI Program with qualifying medical diagnosis. diagnosis.

• In addition to the referenced ICD

In addition to the referenced ICD-

• 9 codes, vision

9 codes, vision therapy services performed in therapy services performed in-

• office are reported
• ffice are reported

with CPT code 92065. with CPT code 92065.

Vision Therapy Coding Vision Therapy Coding

ABI Program ABI Program Diagnosis Code Diagnosis Code Description Description

438.7 438.7 Disturbances of vision Disturbances of vision 907.0 907.0 Late effect injury intracranial Late effect injury intracranial injury without mention of skull injury without mention of skull fracture fracture 997.0 997.0 Central Nervous System Central Nervous System complications, not classified complications, not classified elsewhere elsewhere V57.4 V57.4 Care involving orthoptic training Care involving orthoptic training

Top 5 Frequently Top 5 Frequently Asked Questions Asked Questions

• Inquires regarding claim payment or

Inquires regarding claim payment or denial denial

• Checking client eligibility

Checking client eligibility

• Covered services

Covered services

• Prior Authorization

Prior Authorization

• Accessing bulletins via the EqualityCare

Accessing bulletins via the EqualityCare website website

( (http://wyequalitycare.acs http://wyequalitycare.acs-

• inc.com

inc.com) )

Top 10 Denials Top 10 Denials

1 1

Exact duplicate of a previously paid claim. Exact duplicate of a previously paid claim.

2 2

Third Party Liability (TPL) is on the client Third Party Liability (TPL) is on the client’ ’s file and the claim is not s file and the claim is not a crossover. a crossover.

3 3

The client is ineligible on the date of service. The client is ineligible on the date of service.

4 4

Medicare eligibility is on the client Medicare eligibility is on the client’ ’s file and the claim is not a s file and the claim is not a crossover claim. crossover claim.

5 5

The treating provider number is a group number. The treating provider number is a group number.

6 6

The procedure code is missing or invalid. The procedure code is missing or invalid.

7 7

The client number is not on file or is invalid. The client number is not on file or is invalid.

8 8

The treating provider is not eligible for the date of service. The treating provider is not eligible for the date of service.

9 9

Procedure code age conflict. Procedure code age conflict.

10 10

The billing provider is not eligible for the date of service. The billing provider is not eligible for the date of service.

Resources for More I nformation Resources for More I nformation

• Address for Claims and Adjustments:

Address for Claims and Adjustments:

Claims Claims ACS, Inc. ACS, Inc. P.O. Box 547 P.O. Box 547 Cheyenne, WY 82003 Cheyenne, WY 82003-

• 0547

0547

• Address for Correspondence:

Address for Correspondence:

Provider Relations Unit Provider Relations Unit ACS, Inc. ACS, Inc. P.O. Box 667 P.O. Box 667 Cheyenne, WY 82003 Cheyenne, WY 82003-

• 0667

0667

• Telephone Numbers for Provider Relations:

Telephone Numbers for Provider Relations:

Inside Cheyenne Inside Cheyenne – – (307) 772 (307) 772 – – 8401 8401 Outside Cheyenne Outside Cheyenne – – (800) 251 (800) 251 – – 1268 1268 Fax (307) 772 Fax (307) 772 – – 8405 8405 Automated Voice Response (AVR) Automated Voice Response (AVR) – – (307) 772 (307) 772-

• 8403 or (800) 251

8403 or (800) 251-

• 1270

1270

Questions?