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-37 May 2008 TO: Vision Care Providers Participating in MassHealth FROM: Tom Dehner, Medicaid Director RE: Vision Care Manual (Revised Regulations and Service Codes and Descriptions) This letter transmits changes to the vision care program regulations in Subchapter 4 of the Vision Care Manual, as well as the service codes and descriptions in Subchapter 6. These revisions are effective June 1, 2008. I. Changes to Program Regulations (A) Provider Eligibility These revised regulations codify existing eligibility criteria for acute hospital outpatient departments, hospital-licensed health centers and other satellite clinics, and community health centers. Such providers are eligible under 130 CMR 402.404(A) to provide services described as ophthalmic materials dispensing in the revised Subchapter 6. (B) Hearing Aid Services Provided by Opticians Effective June 1, 2008, any dispensing optician who provides hearing-aid services will be required to be licensed by the Massachusetts Board of Registration of Hearing Instrument Specialists and enroll separately as a MassHealth hearing instrument specialist in accordance with 130 CMR 416.000. MassHealth will issue the dually licensed optician/hearing instrument specialist a separate provider number to use when billing for hearing-aid services. MassHealth will no longer pay for hearing aid services billed using a MassHealth optician’s provider number after June 1, 2008. (C) Transportation for Out of Office Services (Service Code T2002) Through Vision Care Bulletin 14 (July 2007), MassHealth implemented a policy change effective for dates of service on or after June 1, 2007. At that time, MassHealth expanded the use of Service Code T2002 allowing providers to bill once per member per date of service for certain services provided out of the office. These revisions are effective June 1, 2008, but some changes codify the policy that went into effect on June 1, 2007. (D) Other Clarifications These revised regulations include clarifications to prior-authorization and eyeglass- replacement policies, update the introductory description of vision care services to more accurately reflect the range of covered services; and allow for payment for services provided at other locations of service as approved by MassHealth. II. Changes to Service Codes and Descriptions Effective June 1, 2008, modifier 52 must be used only when billing for eye examinations performed without cycloplegic or mydriatic drops. Modifier 52 is no longer required when billing for additional patients seen in the nursing facility. In addition, new service codes have been added, and Subchapter 6 has been redesigned for clarity. III. Other Reminders (A) Modifiers TC/26 Please note that modifiers TC and 26 do not apply to services provided by optometrists, opticians, or ocularists. Do not submit claims or requests for prior authorization using these modifiers. (B) Date of Service When billing for the dispensing of vision care materials, the date of service is the date on which the vision care materials are delivered to the member, not the date of the initial eye exam, nor the date the materials are ordered. The date of service for all other vision care services is the date on which the medical service is provided to the member. If you wish to obtain a fee schedule, you may download the Division of Health Care Finance and Policy (DHCFP) regulations at no cost at www.mass.gov/dhcfp. You may also purchase a paper copy of DHCFP regulations from either the Massachusetts State Bookstore or from DHCFP (see addresses and telephone numbers below). You must contact them first to find out the price of the paper copy of the publication. The regulation title for vision care services is 114.3 CMR 15.00: Vision Care Services and Ophthalmic Materials. Massachusetts State Bookstore Division of Health Care Finance and Policy State House, Room 116 Two Boylston Street Boston, MA 02133 Boston, MA 02116 Telephone: 617-727-2834 Telephone: 617-988-3100 www.mass.gov/sec/spr www.mass.gov/dhcfp This transmittal letter and other publications issued by MassHealth are available on the MassHealth Web site at www.mass.gov/masshealth. Click on MassHealth Regulations and Other Publications, then on Provider Library. 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. NEW MATERIAL (The pages listed here contain new or revised language.) Vision Care Manual Pages iv, vi, 4-1 through 4-12, and 6-1 through 6-14 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Vision Care Manual Pages iv, 4-1 through 4-12, 6-5, and 6-6 — transmitted by Transmittal Letter VIS-35 Pages vi, 6-1 through 6-4, and 6-7 through 6-10 — transmitted by Transmittal Letter VIS-34 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Table of Contents Page iv Vision Care Manual Transmittal Letter VIS-37 Date 06/01/08 4. Program Regulations 402.401: Introduction .............................................................................................................. 4-1 402.402: Definitions ................................................................................................................ 4-1 402.403: Eligible Members ...................................................................................................... 4-2 402.404: Provider Eligibility.................................................................................................... 4-2 402.405: Nonreimbursable Circumstances .............................................................................. 4-3 432.406: Maximum Allowable Fees ........................................................................................ 4-3 402.407: Individual Consideration .......................................................................................... 4-4 402.408: Prior Authorization ................................................................................................... 4-4 402.409: Separate Procedure ................................................................................................... 4-4 (130 CMR 402.410 through 402.415 Reserved) 402.416: Prescription and Dispensing Requirements .............................................................. 4-5 402.417: Recordkeeping Requirements ................................................................................... 4-6 402.418: Services Provided Outside the Office ....................................................................... 4-7 (130 CMR 402.419 through 402.425 Reserved) 402.426: Service Limitations: Visual Analysis ...................................................................... 4-8 402.427: Service Limitations: Time and Power Restrictions on Dispensing Eyeglasses ....... 4-8 402.428: Service Limitations: Broken Eyeglasses .................................................................. 4-9 402.429: Service Limitations: Tinted Lenses ......................................................................... 4-9 402.430: Service Limitations: Coated Lenses ....................................................................... 4-10 402.431: Service Limitations: Two Pairs of Eyeglasses Instead of Bifocals ......................... 4-10 402.432: Service Limitations: Cataract Lenses ....................................................................... 4-10 402.433: Service Limitations: Contact Lenses ....................................................................... 4-10 402.434: Service Limitations: Extra or Spare Eyeglasses ...................................................... 4-11 402.435: Service Exclusions .................................................................................................... 4-11 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Table of Contents Page vi Vision Care Manual Transmittal Letter VIS-37 Date 06/01/08 6. Service Codes and Descriptions Introduction........................................................................................................................... 6-1 Definitions............................................................................................................................ 6-1 Explanation of Abbreviations ............................................................................................... 6-2 Service Codes and Descriptions: Visual Analysis ............................................................... 6-2 Service Codes and Descriptions: Supplementary Testing ................................................... 6-11 Service Codes and Descriptions: Contact Lenses ................................................................ 6-12 Service Codes and Descriptions: Contact Lens Services ..................................................... 6-12 Service Codes and Descriptions: Dispensing of Ophthalmic Materials: Fitting of Prescription Spectacles, Glass/Plastic Lenses ................................................................ 6-13 Service Codes and Descriptions: Dispensing of Ophthalmic Materials: Repairs and Replacement Parts .......................................................................................................... 6-13 Service Codes and Descriptions: Miscellaneous ................................................................. 6-14 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/PPHSD Screening Services Codes ............................................................. Z-1 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 402.000) Page 4-1 Vision Care Manual Transmittal Letter VIS-37 Date 06/01/08 402.401: Introduction (A) The regulations in 130 CMR 402.000 state the requirements and procedures for the purchase of vision care services under MassHealth. Vision care services are the professional care of the eyes to examine, diagnose, treat, and manage diseases and disorders of the visual system, the eye, and associated structures. These services include eye examinations, vision training, managing and treating complex eye and vision problems, and the prescription and dispensing of ophthalmic materials. Professional and technical services must be provided in accordance with the established standards of quality and health-care necessity recognized by the vision care industry and licensing agencies in Massachusetts. (B) All vision care providers participating in MassHealth must comply with MassHealth regulations, including but not limited to 130 CMR 402.000 and 450.000. 402.402: Definitions The following terms used in 130 CMR 402.000 have the meanings given in 130 CMR 402.402 unless the context clearly requires a different meaning. The reimbursability of services defined in 130 CMR 402.402 is not determined by these definitions, but by the application of regulations elsewhere in 130 CMR 402.000 and in 130 CMR 450.000. Date of Service – the date of service for dispensing vision care materials is the date on which the vision care materials are delivered to the member. The date of service for all other vision care services is the date on which the medical service is provided to the member. Dispensing Practitioner – any optician, optometrist, ophthalmologist, or other participating provider authorized by the MassHealth agency to dispense eyeglass frames, lenses, and other vision care materials to members. Optical Supplier – the optical laboratory contracted by the MassHealth agency to supply the following ophthalmic materials and services: (1) eyeglass frames; (2) eyeglass lenses; (3) frame cases; (4) tints, coatings, ground-on prisms, and prisms by decentration; and (5) repair or replacement parts. Order – the process by which a dispensing practitioner requests ophthalmic materials (completed eyeglasses, repair parts, and other services) from the optical supplier. Order Form – the form used by the dispensing practitioner to request ophthalmic materials (completed eyeglasses, repair parts, and other services) from the optical supplier. The required form is specified in the instructions in Subchapter 5 of the Vision Care Manual. Prescriber – any optometrist, ophthalmologist, or other practitioner licensed and authorized to write prescriptions for eyeglass frames, lenses, and other vision care services. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 402.000) Page 4-2 Vision Care Manual Transmittal Letter VIS-37 Date 06/01/08 402.403: Eligible Members (A) (1) MassHealth Members. The MassHealth agency pays for vision care services only when provided to eligible MassHealth members, subject to the restrictions and limitations described in MassHealth regulations. 130 CMR 450.105 specifically states, for each MassHealth coverage type, which services are covered and which members are eligible to receive those services. (2) Recipients of the Emergency Aid to the Elderly, Disabled and Children Program. For information on covered services for recipients of the Emergency Aid to the Elderly, Disabled and Children Program, see 130 CMR 450.106. (B) For information on verifying member eligibility and coverage type, see 130 CMR 450.107. 402.404: Provider Eligibility Payment for services described in 130 CMR 402.000 will be made only to providers of vision care services who are participating in MassHealth on the date of service. The eligibility requirements for providers of vision care services are as follows. (A) In State. (1) Optometrists. A Massachusetts optometrist is eligible to participate in MassHealth only if licensed to practice by the Massachusetts Board of Registration in Optometry. (a) A Level I optometrist is one who is not qualified to apply topical agents. (b) A Level II optometrist is one who has obtained a Certificate of Qualification for the Use of Diagnostic Pharmaceutical Agents (DPAs) from the Board of Registration in Optometry. (c) A Level III optometrist is one who has obtained a Certificate of Qualification for the Use of Therapeutic Pharmaceutical Agents (TPAs) from the Board of Registration in Optometry. (2) Opticians. A Massachusetts optician is eligible to participate in MassHealth only if licensed to practice by the Massachusetts Board of Registration of Opticians. In order to provide hearing aid services to MassHealth members, an optician must be separately licensed by the Massachusetts Board of Registration of Hearing Instrument Specialists and must enroll separately in MassHealth as a hearing instrument specialist in accordance with 130 CMR 416.000. A licensed optician cannot provide hearing aid services under 130 CMR 402.000. (3) Ophthalmologists. A Massachusetts ophthalmologist is eligible to participate in MassHealth only if licensed to practice by the Massachusetts Board of Registration in Medicine. An ophthalmologist is governed by these regulations only with respect to the dispensing of ophthalmic materials. All other vision care services provided by an ophthalmologist must be in compliance with MassHealth physician regulations at 130 CMR 433.000. (4) Ocularists. A Massachusetts ocularist is eligible to participate in MassHealth only if certified by the National Examining Board of Ocularists. (5) Acute Hospital Outpatient Departments and Hospital-Licensed Health Centers and Other Satellite Clinics. An acute hospital outpatient departments or hospital-licensed health center or other satellite clinic that participates in MassHealth pursuant to the Executive Office of Health and Human Services (EOHHS) Acute Hospital Request for Applications (RFA) and Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 402.000) Page 4-3 Vision Care Manual Transmittal Letter VIS-37 Date 06/01/08 contract is eligible to provide services under 130 CMR 402.000. Acute hospital outpatient departments and hospital-licensed health centers or other satellite clinics are paid pursuant to 130 CMR 402.000 for services described as ophthalmic materials dispensing in Subchapter 6 of the Vision Care Manual. All other vision care services provided by an acute hospital outpatient department or hospital-licensed health center or other satellite clinic are paid in accordance with the RFA and contract. (6) Community Health Center. A community health center with a current provider agreement with EOHHS for the provision of community health center services is eligible to provide services under 130 CMR 402.000. Community health centers are paid pursuant to 130 CMR 402.000 for services described as ophthalmic materials dispensing in Subchapter 6 of the Vision Care Manual. All other vision care services provided by a community health center are paid in accordance with the community health center regulations at 130 CMR 405.000. (B) Out of State. (1) Optometrists. An optometrist located outside of Massachusetts is eligible to receive payment for vision care services provided to MassHealth members only if the optometrist is licensed to practice by the appropriate state's board of registration. (2) Opticians. An optician located outside of Massachusetts is eligible to receive payment for vision care services provided to MassHealth members only if the optician is licensed to practice by the appropriate state's board of registration. An out-of-state licensed optician cannot provide hearing aid services under 130 CMR 402.000. (3) Ophthalmologists. An ophthalmologist located outside of Massachusetts is eligible to receive payment for vision care services provided to MassHealth members only if the ophthalmologist is licensed to practice by the appropriate state's board of registration. An ophthalmologist is governed by 130 CMR 402.000 only with respect to the dispensing of ophthalmic materials. All other vision care services provided by ophthalmologists must be in compliance with MassHealth physician regulations at 130 CMR 433.000. (4) Ocularists. An ocularist located outside of Massachusetts is eligible to receive payment for vision care services provided to MassHealth members only if the ocularist has been certified by the National Examining Board of Ocularists. 402.405: Nonreimbursable Circumstances With the exception of the dispensing of ophthalmic materials, vision care services are not reimbursable to a vision care provider under 130 CMR 402.000 when the services are furnished in a state institution, in an acute inpatient hospital setting, or when the services are among those for which the provider is otherwise compensated by the state or institution. 402.406: Maximum Allowable Fees The Massachusetts Division of Health Care Finance and Policy (DHCFP) determines the maximum allowable fees for all vision care services and ophthalmic materials, except for those ophthalmic materials purchased through the optical supplier where the basis for the rates is set by the terms of the contract. Payment is always subject to the conditions, exclusions, and limitations set forth in 130 CMR 402.000. The payment for a service will be the lower of the following: (A) the provider's usual and customary fee; or (B) the maximum allowable fee listed in the applicable DHCFP fee schedule. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 402.000) Page 4-4 Vision Care Manual Transmittal Letter VIS- 37 Date 06/01/08 402.407: Individual Consideration Some services listed in Subchapter 6 of the Vision Care Manual are designated "I.C.," an abbreviation for individual consideration. Individual consideration means that a fee could not be established. The payment for an individual-consideration service will be determined by the MassHealth agency’s professional advisors from the provider's descriptive report of the service furnished. 402.408: Prior Authorization (A) For certain services specified in 130 CMR 402.426 through 402.434, the MassHealth agency requires that the provider of the service obtain prior authorization as a prerequisite to payment. In addition, services that are designated in Subchapter 6 of the Vision Care Manual with the abbreviation "P.A." require prior authorization. These services include but are not limited to the following: (1) certain contact lenses; (2) low-vision aids; (3) fundus photographs; (4) unlisted services; (5) glass lenses; (6) high-index lenses; (7) special-needs glasses; (8) polycarbonate lenses for members aged 21 years or older, except for members who are amblyopic or monocular; and (9) vision training. (B) All prior-authorization requests must be submitted in accordance with the instructions in Subchapter 5 of the Vision Care Manual. Prior authorization determines only the medical necessity of the authorized service and does not establish or waive any other prerequisites for payment such as member eligibility or resort to health insurance payment. (C) The MassHealth agency requires prior authorization for the following under EPSDT: (1) any service not listed in Subchapter 6 for an EPSDT-eligible member; and (2) any exception to a limitation on a service otherwise covered for an EPSDT-eligible member as described in 130 CMR 402.000. 402.409: Separate Procedure Some procedures are commonly carried out as an integral part of a total service, and as such do not warrant a separate identification. When, however, such a procedure is performed independently of, and is not immediately related to, other services, it is designated as a "separate procedure" or "S.P." in the service description. Thus, when a procedure is performed alone for a specific purpose, it is considered a separate procedure. (130 CMR 402.410 through 402.415 Reserved) Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 402.000) Page 4-5 Vision Care Manual Transmittal Letter VIS-37 Date 06/01/08 402.416: Prescription and Dispensing Requirements (A) Eyeglasses and other visual aids may be dispensed only upon a written and dated prescription. The prescription must be based upon the results of a vision examination performed by the prescriber. The prescription must include all information that is necessary to enable a dispensing practitioner to order the prescription. (B) The prescriber must provide the member with a signed copy of the prescription without extra charge. The date or dates on which the prescription is filled or refilled must be recorded in the member's medical record. (C) The prescriber may order the prescription or may refer the member to another vision care provider. (D) In order for a dispensing practitioner to be paid for dispensing a prescription involving ophthalmic materials and services available through the optical supplier, all such materials and services must be ordered from the optical supplier. These ophthalmic materials include a specific selection of eyeglass frames for men, women, and children. Members must choose from this selection of frames. Information describing all of the ophthalmic materials and services furnished by the optical supplier is published by the optical supplier and is distributed to vision care providers by the MassHealth agency. (E) In order to receive payment for dispensing an item, the dispensing practitioner must take all necessary measurements, verify lens characteristics, and adjust the completed appliance to the individual. At no additional charge, the dispensing practitioner must continue to make necessary adjustments to the completed appliance for six months after the dispensing date. (F) The optical supplier must replace free of charge any lens containing any defect or error caused by the optical supplier. Such defects or errors include lenses that are broken, scratched, or chipped at the time of receipt by the dispensing practitioner, or lenses that deviate from the dispensing practitioner's prescription beyond the deviation standards permitted in the American National Standards Institute Z80 rulings. This provision is effective only if the defective or incorrect lens is received by the optical supplier from the dispensing practitioner within seven working days after the date on which the optical supplier sent the completed order to the dispensing practitioner, and only if it is accompanied by a copy of the original order form containing a notation of the defect or error. In the event of a dispute between the optical supplier and a dispensing practitioner about lens deviation, the MassHealth agency determines whether the lens in dispute exceeds deviation standards. (G) Although contractual arrangements are in effect between the MassHealth agency and the optical supplier, all regulations about reimbursable and nonreimbursable services, including prior- authorization requirements, are applicable to all dispensing practitioners. (H) An order to the optical supplier for prescribed items constitutes a representation by the dispensing practitioner that the person for whom the prescribed item is ordered is an eligible member as of the date of the order. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 402.000) Page 4-6 Vision Care Manual Transmittal Letter VIS-37 Date 06/01/08 402.417: Recordkeeping Requirements (A) A vision care provider must maintain a suitable medical record for each member for a period of at least as long as the minimum period required by 130 CMR 450.205(G). The record must fully disclose all pertinent information about the services furnished, including the date of service, the dates on which materials were ordered and dispensed, and a description of materials ordered and dispensed (including the frame style and the manufacturer's name). All findings resulting from a visual analysis, whether they are normal or abnormal, must be recorded. When extenuating circumstances prevent the use of one or more procedures normally done in a visual analysis, the record must contain the reasons that the tests were not performed. (B) For comprehensive eye examinations and diagnoses performed in the office, a nursing facility, a hospital, or the member's home, the record must contain the following information or test results: (1) case history; (2) visual acuity testing; (3) ophthalmoscopy and external eye health examination; (4) ocular mobility testing, heterophoria testing, and fusion testing; (5) pupillary reflex testing; (6) refraction (retinoscopy, subjective refraction, and keratometry); (7) confrontation fields or other screening tests; (8) tonometry, when medically indicated; (9) case analysis and disposition; and (10) biomicroscopy, when medically indicated. (C) All consultation services must be fully documented in the record. A record for a consultation must contain the following information: (1) the member's complaints and symptoms; (2) the condition of the eye; and (3) if applicable, the name of the person to whom a referral was made. (D) All screening services must be fully documented in the member’s record. A record for a screening service must note the chief complaint and must contain all findings of two or more of the following tests: (1) distance vision and near vision; (2) cover test; (3) visual skills; (4) tonometry; and (5) biomicroscopy. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 402.000) Page 4-7 Vision Care Manual Transmittal Letter VIS-37 Date 06/01/08 402.418: Services Provided Outside the Office (A) Member's Home. The MassHealth agency pays for vision care services provided to a member in the member's home. A medical record must be kept on file at the provider's office. (B) Nursing Facility. The MassHealth agency pays an optometrist or an ophthalmologist for performing an eye examination for a member residing in a nursing facility only when the optometrist or ophthalmologist is specifically requested to do so by the medical director, the nursing director, or responsible staff member at the facility, or by the member's personal physician. The request must be documented in the member's record at the facility. If eyeglasses are to be dispensed to a member in the facility, the facility must document in the member's record that a consultation has occurred between the facility's staff member and the optometrist or ophthalmologist, and that they have determined that the member is able to benefit from eyeglasses. A copy of the eye-examination results, including the prescription, must be filed in the member's record at the facility and at the optometrist's or ophthalmologist's office. (C) Other Facilities. The MassHealth agency pays for vision care services provided to a member residing in a public or private facility, if payment for these services is not included in the facility's rate. A medical record must be kept on file at the provider's office. (D) Other Locations of Service. The MassHealth agency pays for vision care services provided to eligible members at other places of service as approved by the MassHealth agency. (E) Claims for Payment. (1) A visual analysis performed for a member outside of the office must be claimed using the appropriate service codes. (See Subchapter 6 of the Vision Care Manual.) (2) The MassHealth agency pays separately for transportation once per member per date of service for each member for whom the provider delivered or picked up eyeglasses, or to whom vision care services were provided out of the office in accordance with 130 CMR 402.418(A) through (D). (130 CMR 402.419 through 402.425 Reserved) Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 402.000) Page 4-8 Vision Care Manual Transmittal Letter VIS-37 Date 06/01/08 402.426: Service Limitations: Visual Analysis (A)(1) The MassHealth agency does not pay for a comprehensive eye examination in an optometrist's office or a visual analysis in a home or nursing facility if a comprehensive eye examination or a visual analysis has been furnished: (a) within the preceding 12 months, for a member under the age of 21; or (b) within the preceding 24 months, for a member aged 21 or older. (2) These restrictions do not apply if there is a referral from the member's physician or if one of the following complaints or conditions is documented in the member's record: (a) blurred vision; (b) evidence of headaches; (c) systemic diseases such as diabetes, hyperthyroidism, or HIV; (d) cataracts; (e) pain; (f) redness; or (g) infection. (B) The MassHealth agency pays for a consultation service only if it is provided independently of a comprehensive eye examination. (C) The MassHealth agency does not pay for more than two screening services per 12 month period. (D) A comprehensive eye examination includes a screening service. The provider cannot bill separately for both a screening service and a comprehensive eye examination for the same member. The MassHealth agency pays for only the comprehensive eye exam. (E) The MassHealth agency does not pay for a tonometry as a separate service when it is performed as part of a comprehensive eye examination, a consultation, or a screening service. When a tonometry is performed as a separate service to monitor a member who has glaucoma, the provider must use the appropriate service code (see Subchapter 6 of the Vision Care Manual). 402.427: Service Limitations: Time and Power Restrictions on Dispensing Eyeglasses (A) The MassHealth agency pays for only one initial pair of eyeglasses and only if there is a corrective power of at least +.75D sphere or +.50D cylinder. (See 130 CMR 402.431 for an exception permitting two pairs of eyeglasses instead of bifocals and 130 CMR 402.434 regarding spare eyeglasses.) (B) The MassHealth agency pays for one replacement of a pair of lost or stolen eyeglasses within the first 12 months after dispensing only if there is a corrective power of at least +.75D sphere or +.50D cylinder. Subsequent replacement of a pair of lost or stolen eyeglasses within the 12-month period requires prior authorization. (C) The MassHealth agency pays for a new pair of lenses with a different prescription only if there is a change from the current prescription of at least +.50D sphere or cylinder; or an axis change of at least 3ş for a +1.00D cylinder or over, 5ş for a +.75D cylinder, or 10ş for a +.50D cylinder. (D) The MassHealth agency pays for a plano lens (no correction required) for a member who is monocular. Prior authorization is not required. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 402.000) Page 4-9 Vision Care Manual Transmittal Letter VIS-37 Date 06/01/08 402.428: Service Limitations: Broken Eyeglasses (A) The MassHealth agency pays for the repair of broken eyeglasses, including the replacement of broken parts, subject to the following limitations. (1) If a broken frame can be repaired and replacement parts are available from the optical supplier, the MassHealth agency pays for repair rather than replacement. If replacement parts are not available from the optical supplier, the MassHealth agency pays for an entire replacement frame. (2) Except for members under the age of 21, the MassHealth agency does not pay without prior authorization for the replacement of broken frames and lenses if a repair of either broken frames or lenses was furnished within the preceding 12 months. (3) Dispensing practitioners must order replacement eyeglass frames, lenses, and repair parts from the optical supplier. Dispensing practitioners must use the order form to obtain replacement parts. (4) When there is damage to eyeglass frames or lenses that were not fabricated by the optical supplier, dispensing practitioners must adhere to the following procedure: (a) the member must be instructed to choose a new frame from the selection available through MassHealth; and (b) using the new frame that has been selected and the member's lens prescription, the dispensing practitioner must order a completely new pair of eyeglasses from the optical supplier. (5) Payment for dispensing replacement lenses may be claimed under the appropriate service code (see Subchapter 6 of the Vision Care Manual) where applicable for the lens being dispensed, but only if each broken lens meets the minimum power criteria for an initial pair of eyeglasses as described in 130 CMR 402.427(A). (B) The appropriate service codes (see Subchapter 6 of the Vision Care Manual) must be used when submitting claims for dispensing replacement frames or parts of frames. 402.429: Service Limitations: Tinted Lenses (A) The MassHealth agency pays for "pink l" and "pink 2" colored lenses, up to 25 percent absorption or equal-density tint, if at least one of the following conditions applies: (1) the member has a pathological or other abnormal condition such as aphakia; or (2) the member has habitually worn tinted lenses of this nature, and the prescriber concludes that the member should continue to wear them. The MassHealth agency does not pay for tinted lenses prescribed only because the member complains of photophobia. (B) Any condition that warrants the use of tinted lenses must be fully documented in the member's record. (C) In some situations, other tints (available for plastic lenses only) may be medically justified. Any condition that warrants the use of tinted lenses of this nature must be fully documented in the member's medical record, and may be ordered from the optical supplier only after the provider has received prior authorization from the MassHealth agency. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 402.000) Page 4-10 Vision Care Manual Transmittal Letter VIS-37 Date 06/01/08 402.430: Service Limitations: Coated Lenses The MassHealth agency pays for coated lenses only when they are needed to give equal-density tint or, using clear coatings only, to prevent excessive reflective glare. Any condition that warrants the use of coated lenses must be fully documented in the member's medical record. 402.431: Service Limitations: Two Pairs of Eyeglasses Instead of Bifocals The MassHealth agency pays for two pairs of eyeglasses instead of bifocals if one or more of the following conditions exists. Any condition listed below that warrants the use of two pairs of eyeglasses instead of bifocals must be fully documented in the member's medical record. (A) The member's prescription cannot satisfactorily be made into bifocal lenses. (B) The member has shown an inability to adjust to bifocals. (C) The member has a physical disability (for example, severe arthritis) that would preclude or impede adjustment to bifocals. (D) The member's advanced age would make adjustment to bifocals unduly difficult. (E) The member's occupation would make bifocals hazardous. (F) The member has a marked facial asymmetry. 402.432: Service Limitations: Cataract Lenses The MassHealth agency does not pay for glass cataract lenses. All aphakic prescriptions for members requiring cataract lenses must specify plastic lenticular aspheric lenses only. Any condition that warrants the use of cataract lenses must be fully documented in the member's medical record. 402.433: Service Limitations: Contact Lenses (A) The MassHealth agency pays for hard, soft, or gas-permeable contact lenses if one or more of the following conditions exists: (1) postoperative cataract extraction; (2) keratoconus; (3) anisometropia of more than 3.00D; or (4) more than 7.00D of myopia or hyperopia. (B) Any condition that warrants the use of hard, soft, or gas-permeable contact lenses must be fully documented in the member's medical record. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 402.000) Page 4-11 Vision Care Manual Transmittal Letter VIS-37 Date 06/01/08 402.434: Service Limitations: Extra or Spare Eyeglasses The MassHealth agency pays for an extra or spare pair of eyeglasses on a prior-authorization basis only. Any condition that warrants the use of an extra or spare pair of eyeglasses must be fully documented in the member's medical record. The MassHealth agency grants a prior- authorization request for extra or spare eyeglasses only if one or more of the following conditions exists: (A) aphakia; (B) more than 7.00D of myopia or hyperopia; or (C) more than 3.00D of astigma. 402.435: Service Exclusions (A) The MassHealth agency does not pay for any of the following services or materials: (1) absorptive lenses of greater than 25 percent absorption; (2) prisms obtained by decentration; (3) treatment of congenital dyslexia (the Massachusetts Department of Education may offer resources for the treatment of this condition); (4) routine adjustments or follow-up visits to check visual acuity and ocular comfort (payment for such visits is included in the dispensing fee for six months after the date on which the eyeglasses were dispensed); (5) contact lenses for extended-wear use; (6) invisible bifocals; (7) the Welsh 4-Drop Lens; and (8) substitutions. (B) (1) If a member desires a substitute for, or a modification of, a reimbursable item, such as designer frames, the member must pay for the entire cost of the eyeglasses, including dispensing fees. The MassHealth agency does not pay for a portion of the cost of the eyeglasses. In all such instances, the provider must inform the member of the availability of reimbursable items before dispensing nonreimbursable items. (2) It is unlawful (M.G.L. c. 6A, § 35) for a provider to accept any payment from a member for a service or item for which payment is available under MassHealth. If a member claims to have been misinformed about the availability of reimbursable items, it will be the responsibility of the provider to prove that the member was offered a reimbursable item, refused it, and chose instead to accept and pay for a nonreimbursable item. REGULATORY AUTHORITY 130 CMR 402.000: M.G.L. c. 118E, §§ 7 and 12. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 402.000) Page 4-12 Vision Care Manual Transmittal Letter VIS-37 Date 06/01/08 This page is reserved. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6 Service Codes Page 6-1 Vision Care Manual Transmittal Letter VIS-37 Date 06/01/08 601 Introduction MassHealth pays for the services represented by the codes listed in Subchapter 6 in effect at the time of service, subject to all conditions and limitations in MassHealth regulations at 130 CMR 402.000 and 450.000. A vision care provider may request prior authorization for any medically necessary service reimbursable under the federal Medicaid Act in accordance with 130 CMR 450.144, 42 U.S.C. §§ 1396d(a)(4)(B), and 42 U.S.C. § 1396d(r)(5) for a MassHealth Standard or CommonHealth member younger than 21 years of age, even if it is not designated as covered or payable in Subchapter 6 of the Vision Care Manual. 602 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. (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. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6 Service Codes Page 6-2 Vision Care Manual Transmittal Letter VIS-37 Date 06/01/08 602 Definitions (cont.) (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. 603 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 be performed alone for a specific purpose to receive the separate fee. (See 130 CMR 402.409.) 604 Service Codes and Descriptions: Visual Analysis Use Modifier 52 (reduced services) when billing for eye examinations performed without cycloplegic or mydriatic drops. Service Code Service Description EVALUATION AND MANAGEMENT (E/M) SERVICES – OPTOMETRISTS ONLY 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 Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self limited or minor. Physicians typically spend 10 minutes face-to-face with the patient and/or family. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6 Service Codes Page 6-3 Vision Care Manual Transmittal Letter VIS-37 Date 06/01/08 604 Service Codes and Descriptions: Visual Analysis (cont.) Service Code Service Description 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 Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend 20 minutes face-to-face with the patient and/or family. 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 Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate severity. Physicians typically spend 30 minutes face-to-face with the patient and/or family. 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 Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 45 minutes face-to-face with the patient and/or family. 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 Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 60 minutes face-to-face with the patient and/or family. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6 Service Codes Page 6-4 Vision Care Manual Transmittal Letter VIS-37 Date 06/01/08 604 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 Usually, the presenting problem(s) are minimal. Typically, 5 minutes are spent performing or supervising these services. 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 Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self limited or minor. Physicians typically spend 10 minutes face-to-face with the patient and/or family. 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 Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend 15 minutes face-to-face with the patient and/or family. 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 Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 25 minutes face-to-face with the patient and/or family. 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 Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 40 minutes face-to-face with the patient and/or family. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes Page 6-5 Vision Care Manual Transmittal Letter VIS-37 Date 06/01/08 604 Service Codes and Descriptions: Visual Analysis (cont.) Service Code Service Description Office or Other Outpatient 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 Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self limited or minor. Physicians typically spend 15 minutes face-to-face with the patient and/or family. 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 Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low severity. Physicians typically spend 30 minutes face-to-face with the patient and/or family. 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 Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate severity. Physicians typically spend 40 minutes face-to-face with the patient and/or family. 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 Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 60 minutes face-to-face with the patient and/or family. 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 Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 80 minutes face-to-face with the patient and/or family. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes Page 6-6 Vision Care Manual Transmittal Letter VIS-37 Date 06/01/08 604 Service Codes and Descriptions: Visual Analysis (cont.) Service Code Service Description Inpatient Consultations 99251 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 Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self limited or minor. Physicians typically spend 20 minutes at the bedside and on the patient’s hospital floor or unit. 99252 Inpatient 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. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low severity. Physicians typically spend 40 minutes at the bedside and on the patient’s hospital floor or unit. 99253 Inpatient 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. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate severity. Physicians typically spend 55 minutes at the bedside and on the patient’s hospital floor or unit. 99254 Inpatient 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. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 80 minutes at the bedside and on the patient’s hospital floor or unit. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6 Service Codes Page 6-7 Vision Care Manual Transmittal Letter VIS-37 Date 06/01/08 604 Service Codes and Descriptions: Visual Analysis (cont.) Service Code Service Description 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 Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the problem(s) requiring admission are of low severity. Physicians typically spend 25 minutes with the patient and/or family or caregiver. 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 Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the problem(s) requiring admission are of moderate severity. Physicians typically spend 35 minutes with the patient and/or family or caregiver. 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 Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the problem(s) requiring admission are of high severity. Physicians typically spend 45 minutes with the patient and/or family or caregiver. 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; and - straightforward medical decision making Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is stable, recovering, or improving. Physicians typically spend 10 minutes with the patient and/or family or caregiver. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6 Service Codes Page 6-8 Vision Care Manual Transmittal Letter VIS-37 Date 06/01/08 604 Service Codes and Descriptions: Visual Analysis (cont.) Service Code Service Description 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; and - medical decision making of low complexity Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is responding inadequately to therapy or has developed a minor complication. Physicians typically spend 15 minutes with the patient and/or family or caregiver. 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; and - medical decision making of moderate complexity Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient has developed a significant complication or a significant new problem. Physicians typically spend 25 minutes with the patient and/or family or caregiver. 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; and - medical decision making of high complexity Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. The patient may be unstable or may have developed a significant new problem requiring immediate physician attention. Physicians typically spend 35 minutes with the patient and/or family or caregiver. Domiciliary or Rest Home E/M Visits: New or Established Patient 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 Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is unstable or has developed a significant new problem requiring immediate physician attention. Physicians typically spend 75 minutes with the patient and/or family or caregiver. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6 Service Codes Page 6-9 Vision Care Manual Transmittal Letter VIS-37 Date 06/01/08 604 Service Codes and Descriptions: Visual Analysis (cont.) Service Code Service Description 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; and - medical decision making of moderate to high complexity Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. The patient may be unstable or may have developed a significant new problem requiring immediate physician attention. Physicians typically spend 60 minutes with the patient and/or family or caregiver. Home Services 99341 Home visit for the evaluation and management of a new patient, which requires these 3 key components: - a problem focused history; - a problem focused examination; and - straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low severity. Physicians typically spend 20 minutes face-to-face with the patient and/or family. 99342 Home visit for the evaluation and management of a new patient, which requires these 3 key components: - an expanded problem focused history; - an expanded problem focused examination; and - medical decision making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate severity. Physicians typically spend 30 minutes face-to-face with the patient and/or family. 99343 Home visit for the evaluation and management of a new patient, which requires these 3 key components: - a detailed history; - a detailed examination; and - medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 45 minutes face-to-face with the patient and/or family. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6 Service Codes Page 6-10 Vision Care Manual Transmittal Letter VIS-37 Date 06/01/08 604 Service Codes and Descriptions: Visual Analysis (cont.) Service Code Service Description 99344 Home visit for the evaluation and management of a new patient, which requires these 3 key components: - a comprehensive history; - a comprehensive examination; and - medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of high severity. Physicians typically spend 60 minutes face-to-face with the patient and/or family. 99347 Home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: - a problem focused interval history; - a problem focused examination; and - straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self limited or minor. Physicians typically spend 15 minutes face-to-face with the patient and/or family. 99348 Home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: - an expanded problem focused interval history; - an expanded problem focused examination; and - medical decision making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend 25 minutes face-to-face with the patient and/or family. 99349 Home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: - a detailed interval history; - a detailed examination; and - medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 40 minutes face-to-face with the patient and/or family. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6 Service Codes Page 6-11 Vision Care Manual Transmittal Letter VIS-37 Date 06/01/08 604 Service Codes and Descriptions: Visual Analysis (cont.) Service Code Service Description OPHTHALMOLOGICAL OR OTHER SERVICES PROVIDED DURING AN E/M VISIT, NEW OR ESTABLISHED PATIENT – OPTOMETRISTS ONLY 67820 Correction of trichiasis; epilation, by forceps only 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 605 Service Codes and Descriptions: Supplementary Testing Service Code Service Description SUPPLEMENTARY TESTING – OPTOMETRISTS ONLY 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 30ş, 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, posterior segment, (e.g., scanning laser) with interpretation and report, unilateral SUPPLEMENTARY TESTING – LEVEL II AND LEVEL III 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 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6 Service Codes Page 6-12 Vision Care Manual Transmittal Letter VIS-37 Date 06/01/08 605 Service Codes and Descriptions: Supplementary Testing (cont.) Service Code Service Description 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 606 Service Codes and Descriptions: Contact Lenses Service Code Service Description CONTACT LENSES – OPTICIANS AND OPTOMETRISTS ONLY 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.) 607 Service Codes and Descriptions: Contact Lens Services Service Code Service Description CONTACT LENS PROFESSIONAL SERVICES – OPTICIANS AND OPTOMETRISTS ONLY 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 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6 Service Codes Page 6-13 Vision Care Manual Transmittal Letter VIS-37 Date 06/01/08 608 Service Codes and Descriptions: Dispensing of Ophthalmic Materials: Fitting of Prescription Spectacles, Glass/Plastic Lenses Service Code Service Description FITTING OF SPECTACLES – ACUTE HOSPITALS, COMMUNITY HEALTH CENTERS, OPHTHALMOLOGISTS, OPTICIANS, AND OPTOMETRISTS ONLY 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) 609 Service Codes and Descriptions: Dispensing of Ophthalmic Materials: Repairs and Replacement Parts REPAIRS AND REPLACEMENT PARTS – ACUTE HOSPITALS, COMMUNITY HEALTH CENTERS, OPHTHALMOLOGISTS, OPTICIANS, AND OPTOMETRISTS ONLY 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) Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6 Service Codes Page 6-14 Vision Care Manual Transmittal Letter VIS-37 Date 06/01/08 610 Service Codes and Descriptions: Miscellaneous Service Code Service Description MISCELLANEOUS – OCULARISTS, OPHTHALMOLOGISTS, OPTICIANS, AND OPTOMETRISTS 99173 Screening test of visual acuity, quantitative, bilateral (use for titmus vision test) T2002 Nonemergency transportation, per diem (once per member per date of service for each member for whom the provider delivered or picked up eyeglasses, or to whom vision care services were provided out of the office) V2799 Vision service, miscellaneous (P.A.) (I.C.) MISCELLANEOUS – OPHTHALMOLOGISTS, OPTICIANS, AND OPTOMETRISTS ONLY 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.) MISCELLANEOUS – OCULARISTS ONLY 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.) 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.