Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid 600 Washington Street Boston, MA 02111 www.mass.gov/masshealth MASSHEALTH TRANSMITTAL LETTER VIS-34 April 2006 TO: Vision Care Providers Participating in MassHealth FROM: Beth Waldman, Medicaid Director RE: Vision Care Manual (Changes to Service Codes and Descriptions) This letter transmits revisions to the service codes and descriptions in the Vision Care Manual. The Centers for Medicare and Medicaid Services (CMS) have revised the Healthcare Common Procedure Coding System (HCPCS) for 2006. The revised Subchapter 6 is effective for dates of service on or after January 1, 2006. Nine codes have been added and eight codes have been deleted. The new codes replace the deleted codes as described on the following chart. Deleted Codes Replacement Codes 99301 99304 99302 99305 99303 99306 99311 99307 99312 99308 99313 99309 and 99310 99323 99328 99333 99337 If you wish to obtain a fee schedule, you may purchase Division of Health Care Finance and Policy regulations from either the Massachusetts State Bookstore or directly from the Division of Health Care Finance and Policy (see addresses and telephone numbers below). You must contact them first to find out the price of the regulation. The Division of Health Care Finance and Policy also has the regulations available on disk. The regulation title for vision care services is 114.3 CMR 15.00: Vision Care Services and Ophthalmic Materials. Massachusetts State Bookstore State House, Room 116 Boston, MA 02133 Telephone: 617-727-2834 www.mass.gov/sec/spr Division of Health Care Finance and Policy Two Boylston Street Boston, MA 02116 Telephone: 617-988-3100 www.mass.gov/dhcfp If you have any questions about the information in this transmittal letter, please contact MassHealth Customer Service at 1-800-841-2900, e-mail your inquiry to providersupport@mahealth.net, or fax your inquiry to 617-988-8974. MASSHEALTH TRANSMITTAL LETTER VIS-34 April 2006 Page 2 NEW MATERIAL (The pages listed here contain new or revised language.) Vision Care Manual Pages vi and 6-1 through 6-10 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Vision Care Manual Pages vi and 6-5 through 6-8 — transmitted by Transmittal Letter VIS-33 Pages 6-1 through 6-4, 6-9, and 6-10 — transmitted by Transmittal Letter VIS-32 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Table of Contents Page vi Vision Care Manual Transmittal Letter VIS-34 Date 01/01/06 6. SERVICE CODES AND DESCRIPTIONS Definitions 6-1 Explanation of Abbreviations 6-2 Service Codes and Descriptions: Visual Analysis 6-3 Service Codes and Descriptions: Supplementary Testing 6-7 Service Codes and Descriptions: Contact Lenses 6-8 Service Codes and Descriptions: Contact Lens Services 6-8 Service Codes and Descriptions: Fitting of Prescription Spectacles, Glass/Plastic Lenses . 6-8 Service Codes and Descriptions: Repairs and Replacement Parts 6-9 Service Codes and Descriptions: Miscellaneous 6-10 Appendix A. Directory A-1 Appendix B. Enrollment Centers B-1 Appendix C. Third-Party-Liability Codes C-1 Appendix W. EPSDT Services: Medical Protocol and Periodicity Schedule W-1 Appendix X. Family Assistance Copayments and Deductibles X-1 Appendix Y. REVS Codes/Messages Y-1 Appendix Z. EPSDT Services Laboratory Codes Z-1 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6 Service Codes Page 6-1 Vision Care Manual Transmittal Letter VIS-34 Date 01/06/05 601 Definitions The following terms used in Subchapter 6 shall have the meanings given below. (A) Consultation — a type of service provided by a physician or an optometrist whose opinion or advice about the evaluation or management of a specific problem is requested by a physician, optometrist, or other appropriate source. (1) A consultant may initiate diagnostic or therapeutic services, or both. (2) The request for a consultation from the attending physician, optometrist, or other appropriate source and the need for consultation must be documented in the patient's medical record. The consultant's opinion and any services that were ordered or performed must also be documented in the patient's medical record and communicated to the requesting physician or other appropriate source. (3) Any procedure identified with a specific CPT code and performed on or subsequent to the date of the initial consultation should be reported separately. If a consultant subsequently assumes responsibility for management of a portion or all of the patient's conditions, the consultation codes should not be used. (B) Established Patient — a patient who has received professional services from the physician or optometrist within the past three years. (C) New Patient — a patient who has not received any professional services from the physician or optometrist within the past three years. (D) Ophthalmological Service Levels (1) Intermediate Services — a level of service pertaining to the evaluation of a new or existing condition complicated with a new diagnostic or management problem not necessarily relating to the primary diagnosis, including history, general medical observation, external ocular and adnexal examination, and other diagnostic procedures as indicated; may include the use of mydriasis. Intermediate services do not usually include determination of the refractive state but may do so in an established patient who is under continuing active treatment. For example: (a) review of history, external examination, ophthalmoscopy, biomicroscopy for an acute complicated condition (for example, iritis) not requiring comprehensive ophthalmological services; and (b) review of interval history, external examination, ophthalmoscopy, biomicroscopy, and tonometry in an established patient with a known cataract not requiring comprehensive ophthalmological services. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6 Service Codes Page 6-2 Vision Care Manual Transmittal Letter VIS-34 Date 01/06/05 601 Definitions (cont.) (2) Extended Services — a level of service requiring an unusual amount of effort or judgment, including a detailed history, review of medical records, examination, and a formal conference with patient, family, or staff, or a comparable medical diagnostic and/or therapeutic service. (3) Comprehensive Services — a level of service in which a general evaluation of the complete visual system is made. The comprehensive services constitute a single service entity but need not be performed at one session. The service includes history, general medical observation, external and ophthalmoscopic examination, gross visual fields, and basic sensorimotor examination. It often includes, as indicated: biomicroscopy, examination with cycloplegia or mydriasis, and tonometry. It always includes initiation of diagnostic and treatment programs as indicated. For example: the comprehensive services required for diagnosis and treatment of a patient with symptoms indicating possible disease of the visual system, such as glaucoma, cataract or retinal disease, or to rule out disease of the visual system, new or established patient. 602 Explanation of Abbreviations The following abbreviations are used in Subchapter 6. (A) “I.C.” indicates that the claim will receive individual consideration to determine payment. (See 130 CMR 402.407.) (B) “P.A.” indicates that prior authorization is required. (See 130 CMR 402.408.) (C) “S.P.” is an abbreviation for separate procedure, and indicates that the procedure is commonly performed as an integral part of a total service and, as such, does not usually warrant a separate fee. The procedure must Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6 Service Codes Page 6-3 Vision Care Manual Transmittal Letter VIS-34 Date 01/06/05 603 Service Codes and Descriptions: Visual Analysis When billing for eye examinations performed without cycloplegic or mydriatic drops or for additional patients seen in a nursing facility, use the modifier 52 (reduced services). Service Code Service Description EVALUATION AND MANAGEMENT (E/M) SERVICES Office or Other Outpatient E/M Visits: New Patient 99201 Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: - a problem-focused history; - a problem-focused examination; and - straightforward medical decision making 99202 Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: - an expanded problem-focused history; - an expanded problem-focused examination; and - straightforward medical decision making 99203 Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: - a detailed history; - a detailed examination; and - medical decision making of low complexity 99204 Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: - a comprehensive history; - a comprehensive examination; and - medical decision making of moderate complexity 99205 Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: - a comprehensive history; - a comprehensive examination; and - medical decision making of high complexity Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6 Service Codes Page 6-4 Vision Care Manual Transmittal Letter VIS-34 Date 01/06/05 603 Service Codes and Descriptions: Visual Analysis (cont.) Service Code Service Description Office or Other Outpatient E/M Visits: Established Patient 99211 Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician 99212 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: - a problem-focused history; - a problem-focused examination; - straightforward medical decision making 99213 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: - an expanded problem-focused history; - an expanded problem-focused examination; - medical decision making of low complexity 99214 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: - a detailed history; - a detailed examination; - medical decision making of moderate complexity 99215 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: - a comprehensive history; - a comprehensive examination; - medical decision making of high complexity Nursing Facility E/M Visits: New or Established Patient 99304 Initial nursing facility care, per day, for the evaluation and management of a patient, which requires these three key components: - a detailed or comprehensive history; - a detailed or comprehensive examination; and - medical decision making that is straightforward or of low complexity 99305 Initial nursing facility care, per day, for the evaluation and management of a patient, which requires these three key components: - a comprehensive history; - a comprehensive examination; and - medical decision making of moderate complexity Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6 Service Codes Page 6-5 Vision Care Manual Transmittal Letter VIS-34 Date 01/06/05 603 Service Codes and Descriptions: Visual Analysis (cont.) Service Code Service Description 99306 Initial nursing facility care, per day, for the evaluation and management of a patient, which requires these three key components: - a comprehensive history; - a comprehensive examination; and - medical decision making of high complexity 99307 Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: - a problem focused interval history; - a problem focused examination; - straightforward medical decision making 99308 Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: - an expanded problem focused interval history; - an expanded problem focused examination; - medical decision making of low complexity 99309 Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: - a detailed interval history; - a detailed examination; - medical decision making of moderate complexity 99310 Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: - a comprehensive interval history; - a comprehensive examination; - medical decision making of high complexity 99328 Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these three key components: - a comprehensive history; - a comprehensive examination; and - medical decision making of high complexity 99337 Domiciliary or rest home visit for the evaluation and management of an established patient, which requires at least two of these three key components: - a comprehensive interval history; - a comprehensive examination; - medical decision making of moderate to high complexity Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6 Service Codes Page 6-6 Vision Care Manual Transmittal Letter VIS-34 Date 01/06/05 603 Service Codes and Descriptions: Visual Analysis (cont.) Service Code Service Description Ophthalmological Services Provided During an E/M Visit, New or Established Patient 92002 Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; intermediate, new patient 92004 comprehensive, new patient, one or more visits 92012 Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established patient 92014 comprehensive, established patient, one or more visits 92015 Determination of refractive state CONSULTATIONS 99241 Office consultation for a new or established patient, which requires these three key components: - a problem-focused history; - a problem-focused examination; and - straightforward medical decision making 99242 Office consultation for a new or established patient, which requires these three key components: - an expanded problem-focused history; - an expanded problem-focused examination; and - straightforward medical decision making 99243 Office consultation for a new or established patient, which requires these three key components: - a detailed history; - a detailed examination; and - medical decision making of low complexity 99244 Office consultation for a new or established patient, which requires these three key components: - a comprehensive history; - a comprehensive examination; and - medical decision making of moderate complexity 99245 Office consultation for a new or established patient, which requires these three key components: - a comprehensive history; - a comprehensive examination; and - medical decision making of high complexity 99251 Initial inpatient consultation for a new or established patient, which requires these three key components: - a problem-focused history; - a problem-focused examination; and - straightforward medical decision making Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6 Service Codes Page 6-7 Vision Care Manual Transmittal Letter VIS-34 Date 01/06/05 604 Service Codes and Descriptions: Supplementary Testing Service Code Service Description SUPPLEMENTARY TESTING – ALL PROVIDERS 92065 Orthoptic and/or pleoptic training, with continuing medical direction and evaluation (P.A.) 92081 Visual field examination, unilateral or bilateral, with interpretation and report; limited examination (e.g., tangent screen, Autoplot, arc perimeter, or single stimulus level automated test, such as Octopus 3 or 7 equivalent) 92082 intermediate examination (e.g., at least 2 isopters on Goldmann perimeter, or semiquantitative, automated suprathreshold screening program, Humphrey suprathreshold automatic diagnostic test, Octopus program 33) 92083 extended examination (e.g., Goldmann visual fields with at least 3 isopters plotted and static determination within the central 30Ί, or quantitative, automated threshold perimetry, Octopus program G-1, 32 or 42, Humphrey visual field analyzer full threshold programs 30-2, 24-2, or 30/60-2) 92100 Serial tonometry (separate procedure) with multiple measurements of intraocular pressure over an extended time period with interpretation and report, same day (e.g., diurnal curve or medical treatment of acute elevation of intraocular pressure) (S.P.) 92135 Scanning computerized ophthalmic diagnostic imaging (e.g., scanning laser) with interpretation and report, unilateral 99173 Screening test of visual acuity, quantitative, bilateral (use for titmus vision test) SUPPLEMENTARY TESTING –LEVEL II OPTOMETRISTS ONLY 76512 Ophthalmic ultrasound, diagnostic; contact B-scan (with or without simultaneous A-scan) 76513 anterior segment ultrasound, immersion (water bath) B-scan or high resolution biomicroscopy 76514 corneal pachymetry, unilateral or bilateral (determination of corneal thickness) 92020 Gonioscopy (separate procedure) (S.P.) 92120 Tonography with interpretation and report, recording indentation tonometer method or perilimbal suction method 92130 Tonography with water provocation 92140 Provocative tests for glaucoma, with interpretation and report, without tonography 92225 Ophthalmoscopy, extended with retinal drawing (e.g., for retinal detachment, melanoma), with interpretation and report; initial 92226 subsequent 92250 Fundus photography with interpretation and report (P.A.) (Both eyes equal one unit.) 92260 Ophthalmodynamometry 92275 Electroretinography with interpretation and report 92285 External ocular photography with interpretation and report for documentation of medical progress (e.g., close-up photography, slit lamp photography, goniophotography, stereo-photography) 92541 Spontaneous nystagmus test, including gaze and fixation nystagmus, with recording 92542 Positional nystagmus test, minimum of four positions, with recording 92544 Optokinetic nystagmus test, bidirectional, foveal or peripheral stimulation, with recording Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6 Service Codes Page 6-8 Vision Care Manual Transmittal Letter VIS-34 Date 01/06/05 605 Service Codes and Descriptions: Contact Lenses Service Code Service Description V2500 Contact lens, PMMA, spherical, per lens V2501 Contact lens, PMMA, toric or prism ballast, per lens V2503 Contact lens, PMMA, color vision deficiency, per lens (P.A.) V2510 Contact lens, gas permeable, spherical, per lens V2511 Contact lens, gas permeable, toric, prism ballast, per lens (P.A.) V2512 Contact lens, gas permeable, bifocal, per lens (P.A.) V2520 Contact lens, hydrophilic, spherical, per lens V2521 Contact lens, hydrophilic, toric or prism ballast, per lens (P.A.) V2522 Contact lens, hydrophilic, bifocal, per lens (P.A.) V2599 Contact lens, other type (P.A.) (I.C.) 606 Service Codes and Descriptions: Contact Lens Services Service Code Service Description 92310 Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens, both eyes, except for aphakia (I.C.) 92326 Replacement of contact lens 607 Service Codes and Descriptions: Fitting of Prescription Spectacles, Glass/Plastic Lenses Service Code Service Description 92340 Fitting of spectacles, except for aphakia; monofocal (use for dispensing entire new initial eyeglasses, or entire new replacement eyeglasses, frame with lenses) 92341 bifocal (use for dispensing entire new initial eyeglasses, or entire new replacement eyeglasses, frame with lenses) 92342 multifocal, other than bifocal (use for dispensing entire new initial eyeglasses, or entire new replacement eyeglasses, frame with lenses) Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6 Service Codes Page 6-9 Vision Care Manual Transmittal Letter VIS-34 Date 01/06/05 608 Service Codes and Descriptions: Repairs and Replacement Parts Service Code-Modifier Service Description 92340-RP Fitting of spectacles, except for aphakia; monofocal – Replacement and repair (use for dispensing replacement single vision lens, glass or plastic, including cataract lenses, per lens) 92341-RP bifocal – Replacement and repair (use for dispensing replacement bifocal lens, glass or plastic, including cataract lenses, per lens) 92342-RP multifocal, other than bifocal – Replacement and repair (use for dispensing replacement multifocal lens, other than bifocal, glass or plastic, including cataract lenses, per lens) 92370 Repair and refitting spectacles; except for aphakia (use for dispensing a replacement frame only, or any replacement frame components such as hinges or temples) 609 Service Codes and Descriptions: Miscellaneous Service Code Service Description V2600 Hand-held low-vision aids and other nonspectacle-mounted aids (P.A.) (I.C.) V2610 Single-lens spectacle-mounted low-vision aids (P.A.) (I.C.) V2615 Telescopic and other compound lens system, including distance vision telescopic, near vision telescopes, and compound microscopic lens system (P.A.) (I.C.) V2623 Prosthetic eye, plastic, custom (I.C.) V2624 Polishing/resurfacing of ocular prosthesis (I.C.) V2625 Enlargement of ocular prosthesis (I.C.) V2626 Reduction of ocular prosthesis (I.C.) V2627 Scleral cover shell (I.C.) V2628 Fabrication and fitting of ocular conformer (I.C.) V2629 Prosthetic eye, other type (P.A.) (I.C.) V2799 Vision service, miscellaneous (P.A.) (I.C.) This publication contains codes that are copyrighted by the American Medical Association. Certain terms used in the service descriptions for HCPCS codes are defined in the Physician's Current Procedural Terminology (CPT) code book. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6 Service Codes Page 6-10 Vision Care Manual Transmittal Letter VIS-34 Date 01/06/05 This page is reserved.