HP Provider Relations October 2010 Vision Services

Vision ServicesOctober Agenda –Objectives –Vision Billing and Coverage –Routine Examinations –CPT ® /HCPCS and Code Sets –Medicare Bypass Table –Frames and Lenses –Replacement Eyeglasses –Billing Members –Written Correspondence –Prior Authorization –ANSI version 5010 –Common Denials –Q&A CPT copyright 2009 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Vision ServicesOctober Objectives –To provide a comprehensive overview of IHCP policy regarding vision services –To explain billing and coverage guidelines for vision services –To inform providers when it is appropriate to bill members for noncovered vision services –To review the most common denial codes for vision claims –To answer questions that may arise throughout the presentation

Vision ServicesOctober Reference Material –Ophthalmological Services are outlined in the IHCP Provider Manual, Chapter 8 –405 IAC 5-23 (Indiana Administrative Code)

Understand Billing procedures

Vision ServicesOctober Coverage and Billing Procedures –The IHCP provides reimbursement for ophthalmology services, subject to the following restrictions: One routine vision care examination and refraction for members 18 years old and younger, per rolling 12-month period One routine vision care examination and refraction for members 19 years old and older, per rolling 24-month period Routine vision examinations may be performed more often than the 12- and 24- month periods described above if they are billed with a medical diagnosis

Vision ServicesOctober Routine Examinations – Common Codes –Procedure codes (not an all-inclusive list) 92002, 92004, 92012, –Diagnosis codes V41, V410, V411 V72, V720, V80, V801, V802 V367X –The routine examination limitations will apply when these procedure codes are billed with these diagnosis codes Error code 6610 – routine vision exam limited to one per 12 months, age 1-18 Error code 6611 – routine vision exam limited to one per 24 months, over age 18 CPT copyright 2009 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Vision ServicesOctober Routine Vision vs. Medical Examinations –The diagnosis code related to the specific procedure code should only reflect the conditions treated on that date of service –Example: a patient is seen for eye pain (379.91), but has a history of hypermetropia/far sightedness (367.0) –If hypermetropia is not evaluated or treated during the current visit, use only diagnosis code –If diagnosis code is included on the claim, the claim will be considered a routine exam subject to the limitations

Vision ServicesOctober Routine Vision vs. Medical Examinations –When a patient is seen for both a medical and routine vision service on the same date, the primary reason for the encounter should be used to determine whether the service falls under the routine or medical benefit –If the primary reason for the visit was eye pain, but a routine vision exam and refraction were performed: The exam should be coded with the eye pain (medical) diagnosis, and the refraction should be coded with the routine diagnosis

Vision ServicesOctober Coverage and Billing Procedures –Providers must use the appropriate Current Procedural Terminology (CPT ® ) or Healthcare Common Procedure Coding System (HCPCS) codes when submitting claims for vision services –Optometrists and opticians are subject to vision service code sets, which are available at –Many vision procedure codes are on the Medicare bypass table Claims for "dually eligibles" do not have to be billed to Medicare first Exams/services (92002, 92004, 92012, 92014, 92015, 92065, 92315, 92316) Frames (V2020, V2025); lenses (V2100-V2615) –All claims must reflect a date of service, which is the date the specific services were actually supplied, dispensed, or rendered to the patient

Vision ServicesOctober Vision Services and Package B –Generally, a routine eye exam and refraction would not be related to the pregnancy, a complication thereof, or a condition that if left untreated would lead to a higher level of care –However, if the member’s primary medical provider (PMP) has specifically referred the member for evaluation of a condition that may affect the pregnancy, the service would be covered under Package B Examples:  Diabetes with retinopathy  Severe eye infection

Vision ServicesOctober Lenses –The IHCP only reimburses for tints 1 and 2 V2745 U1 – Tint, plastic, rose 1 or 2, per lens V2745 U2 - Tint, glass, rose 1 or 2, per lens –The IHCP covers safety lenses only for corneal lacerations and other severe intractable ocular or ocular adnexal disease

Vision ServicesOctober Lenses – Noncovered –The IHCP does not cover the following: V2702 – Deluxe lens feature V2744 – Tint, photochromic V2750 – Antireflective coating V2760 – Scratch resistant coating V2781 – Progressive lenses V2782 – Lens, index plastic, or 1.60 to 1.79 glass V2783 – Lens, index >= 1.66 plastic, or >= 1.80 glass V2786 – Specialty multi-focal lens –If a member chooses to upgrade to one of these codes Provider bills the IHCP for the basic lens code Provider may bill the member for the upgrade portion as long as noncoverage is explained and a waiver is signed

Vision ServicesOctober Lenses –Polycarbonate lenses Are covered only for medically necessary conditions that require additional ocular protection Examples of medical necessity −Member has carcinoma in one eye, and the healthy eye requires corrective lens −Member has eye surgery and still requires corrective lens Patient charts must support medical necessity –Contact lenses Are covered when medically necessary Examples of medical necessity −Severe facial deformity −Severe allergies to all frame materials Providers can bill codes through 92326, in addition to general ophthalmology services Patient charts must support medical necessity

Vision ServicesOctober Frames –The IHCP reimburses for frames including, but not limited to, plastic or metal Procedure code V2020 –Deluxe or fancy frames are covered only when medically necessary Procedure code V2025 Submit documentation outlining medical necessity with claim  Examples Facial deformity Allergic reaction to standard frame material Provision of special sized frames for an infant Submit an invoice with the claim; reimbursement is 90% of retail price –If the member chooses to upgrade to a deluxe frame, the entire frame is noncovered, and the member can be billed Member must sign a waiver prior to service being rendered

Vision ServicesOctober Replacement Eyeglasses –Members who have met medical necessity guidelines for replacement eyeglasses are eligible for a new pair of eyeglasses Younger than 19 years of age: eligible one year from date IHCP provided their original or replacement eyeglasses 19 years of age and older: eligible two years from date IHCP provided their original or replacement eyeglasses –The member must meet the following medical necessity guidelines in at least one eye for the provision of eyeglasses, including replacements A change of 0.75 diopters for patients 6 to 42 years old A change of 0.50 diopters for patients more than 42 years old An axis change of at least 15 degrees

Vision ServicesOctober Modifiers for Replacement Eyeglasses –Replacement eyeglasses due to loss, theft, or damage beyond repair, prior to the frequency guidelines, should be billed with modifier RP or U8 –Replacement eyeglasses due to change in prescription, prior to the frequency guidelines, should be billed with modifier SC –Use of either modifier indicates appropriate documentation is on file in the patient’s record to substantiate the need

Vision ServicesOctober Billing Members Providers may bill IHCP members for services exceeding the benefit limitations under the following circumstances: –If the Eligibility Verification System (EVS) shows that a limitation has been met: Inform the member the service will be noncovered and they will be billed Have the member sign a waiver –If EVS does not show that benefits have been exhausted: Provider may ask the member or guardian to attest in writing that they have not received the service within the past one or two years (depending on age) Inform the member if they are misrepresenting, and the claim is denied, the member will be responsible for the charges

Vision ServicesOctober Written Correspondence –Providers may send an inquiry to the HP Written Correspondence Unit to determine whether a member has exceeded service limitations HP Provider Written Correspondence P.O. Box 7263 Indianapolis, IN –Allow 10 business days for a response Responses are mailed to the "pay to" address –Use IHCP Inquiry Form Available at

Vision ServicesOctober EVS – Benefit Limits Reached –The Benefit Limits Reached information on vision services contained in the Eligibility Verification System may not always be up to date on members covered by the Hoosier Healthwise, risk-based managed care program –Providers should contact the managed care entity (MCE) vision plan to inquire about vision services benefit limits –If the MCE’s vision plan is not able to provide information on vision benefit limits reached, the provider may obtain an attestation waiver from the member The member attests he/she is eligible for the exam/eye wear, and if they are mis-informing they understand they will be liable

Vision ServicesOctober Business Practice to Restrict Services –Providers may establish a business practice to refuse or restrict certain services that are provided to the general public –The provider must establish a written policy in order to do so –If a provider intends to provide exams, diagnostic services, surgical services, but will not provide eyewear, the member must be advised at the time the appointment is made that the provider does not provide “IHCP approved glasses" –A prescription may be provided for the member to have filled at a participating eyewear provider, or the member may choose to find another provider that will furnish both services

Vision ServicesOctober Prior Authorization –For Traditional Medicaid, prior authorization is not required for vision care services except for the following provisions: Blepharoplasty for a significant obstructive vision problem Prosthetic device, except eyeglasses Reconstruction or plastic surgery –Risk-based managed care MCEs may have additional prior authorization requirements

Vision ServicesOctober HIPAA 5010 –The mandatory compliance date for ANSI version 5010 and the National Council for Prescription Drug Programs (NCPDP) version D.0 for all covered entities is January 1, 2012 –If submitting claims to the IHCP, you need to prepare for these upgrades to prevent delay in payment –The IHCP and HP will test transactions on a scheduled basis –Specific transaction testing dates will be provided at a future date

Vision ServicesOctober HIPAA 5010 –Transactions affected by this upgrade: Institutional claims (837I) Dental claims (837D) Medical claims (837P) Pharmacy claims (NCPDP) Eligibility verifications (270/271) Claim status inquiry (276/277) Electronic remittance advices (835) Prior authorizations (278) Managed Care enrollment (834) Capitation payments (820)

Vision ServicesOctober Testing Information –All Trading Partners currently approved to submit 4010A1 and NCPDP 5.1 versions will be required to be approved for 5010 and D.0 transaction compliance All software products used to submit 4010 and NCPDP 5.1 versions must be tested and approved for 5010 and D.0 –Testing will begin January 2011 and include: Clearinghouses, billing services, software vendors, individual providers, provider groups –Providers that exchange data with the IHCP using an IHCP- approved software vendor will not need to test –Each trading partner will be required to submit a new Trading Partner Agreement

Vision ServicesOctober What You Need To Do –If you bill IHCP directly Begin the process to upgrade to the ANSI 5010 or NCPDP D.0 versions –If you are using a billing service or clearinghouse Find out if they are preparing for the HIPAA upgrades to ANSI v5010 and NCPDP vD.0 IHCP Companion Guides will be available during the fourth quarter of 2010 –Questions should be directed to OR –Call the EDI Solutions Service Desk or (317) –Watch for additional information on the testing process, revised IHCP Companion Guides, and the schedule for transaction testing on this mandated initiative in bulletins, banner pages, and newsletters at

Deny Most common denials

Vision ServicesOctober Edit 0593 – Medicare Denied Detail –Cause Medicare has denied at least one detail line on the claim –Resolution Denied detail lines must be rebilled on a separate claim form Do not submit claim as a crossover Include the Medicare Remittance Notice (MRN) with the claim with the reason for the denial Remember: Many vision codes are on the Medicare bypass table and do not need to be billed to Medicare

Vision ServicesOctober Edit 4021 – Procedure Code vs. Program Indicator –Cause Procedure code billed is restricted to a specific program −Package B, C, E −590 Program –Resolution Verify eligibility prior to rendering service Submit claim with appropriate procedure code

Vision ServicesOctober Edit 268 – Billed Amount Missing –Cause The billed amount is missing from one of the detail lines The billed amount is missing from field 28 of CMS-1500 claim form –Resolution Verify each detail line has a billed amount Enter the total billed amount in field 28

Vision ServicesOctober Edit 5001 – Exact Duplicate –Cause Claim is an exact duplicate of a claim in the history file or another claim being processed in the same cycle –Resolution Research prior claims for a paid status  Web interChange  HP Customer Service Center

Vision ServicesOctober Edit 2017 – Recipient Ineligible on DOS Due to Enrollment in Managed Care Entity –Cause The member was not eligible for traditional Medicaid on the date of service because they were enrolled in the risk-based managed care (RBMC) program –Resolution Verify eligibility prior to rendering service to see if the member is in RBMC Bill the appropriate MCE (managed care entity)

Q&A