016.06.05 Ark. Code R. 083

Current through Register Vol. 49, No. 10, October, 2024

Rule 016.06.05-083 - Visual Care Update Transmittal #70 and State Plan Transmittal #2005-011

ATTACHMENT 4.19-B

METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES -OTHER TYPES OF CARE

b. Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of Age and Treatment of Conditions Found

(13)Rye Prostheses and Cleaning

Reimbursement is based on the lesser of the amount billed or the Title XIX (Medicaid) maximum charge allowed. The Medicaid maximum rates were established using the 2005 Medicare fee schedule. The State developed fee schedule rates are the same for both public and private providers of the service and the fee schedule and any annual/periodic adjustments to the fee schedule are published.

(14)Rar Molds

Reimbursement is based on the lesser of the amount billed or 68% of the dealer invoice.

(15)Pesensitization Injections

Medicaid will pay a physician's fee up to the Title XIX (Medicaid) maximum for administering the injection and up to the Title XIX (Medicaid) maximum per vial of antigen. Refer to Attachment 4.19-B, Page 2, Item 5.

Effective for claims with dates of service on or after July 1, 1992, the Title XIX maximum rates were decreased by 20%.

SUBJECT: Provider Manual Update Transmittal #70

213.100Scope of the Adult Program

The primary purpose of this program is for the screening, examination, diagnosis and treatment of conditions of the eye for the prescribing and fitting of eyeglasses, contact lenses and low vision aids for eligible beneficiaries 21 years of age and over.

213.200Coverage and Limitations of the Adult Program

A. One visual examination and/or visual prosthetic device every 24 months from the last date of service.

B. One pair of eyeglasses every 24 months from the last date of service.

C. One prescription services fee every 24 months from the last date of service.

D. Lens replacement as medically necessary with prior authorization.

E. Lens power for single vision must be:

1. +1.00 OR-0.75 sphere.

2. -0.75 axis 90 or 0.75 axis 180 cylinder or at any axis.

F. Tinted lenses, photogray lenses or sunglasses are limited to post-operative cataract or albino patients.

G. Bifocals for presbyopia must have a power of +1.00 and any changes in bifocals must be in increments of at least +0.50.

H. Bifocal lenses are limited to:

1. D-28 and

2. Kryptok.

I. For beneficiaries who are eligible for both Medicare and Medicaid, see Section I for coinsurance and deductible information.

J. Plastic lenses only are covered under the Arkansas Medicaid Program.

K. Low vision aids are covered on a prior authorization basis.

L. Medicaid eligible beneficiaries with the exception of nursing home residents, who are 21 or older, will pay a $2.00 co-payment to the visual care provider for prescription services.

M. Adult diabetics are eligible (with prior authorization) to receive a second pair of eyeglasses within the twenty-four month period if their prescription changes more than one diopter.

N. Eye prosthesis and polishing service are covered on a prior authorization.

214.200Coverage and Limitations of the Under Age 21 Program

A. One examination and one pair of glasses are available to eligible Medicaid beneficiaries every twelve months. Under special circumstances, the Division of Medical Services may issue authorization for a second pair.

B. Prescriptive and acuity minimums must be met before glasses will be furnished. Glasses should be prescribed only if the following conditions apply:

1. The strength of the prescribed lens (for the poorer eye) should be a minimum of -.75D + 1.00D spherical or a minimum of 1.00 cylindrical or the unaided visual acuity of the poorer eye should be worse than 20/30 at a distance.

2. Reading glasses may be furnished based on the merits of the individual case. The doctor should indicate why such corrections are necessary. All such requests will be reviewed on a prior approval basis.

3. If an amblyopic eye cannot be corrected to 20/60 or better, this eye should not be corrected unless the better eye could be corrected to the applicable regulations or by prior approval.

C. Plastic lenses only are covered under the Arkansas Medicaid Program.

D. When the prescription has met the prescriptive and acuity minimum qualifications, Medicaid will purchase eyeglasses through a negotiated contract with an optical laboratory.

The eyeglasses will be forwarded to the doctor's office where he or she will be required to verify the prescription and fit or adjust them to the patient's needs.

E. The eyeglasses must have been originally purchased through the Medicaid Program in order for repairs to be authorized. Any repairs necessary will be made to render the eyeglasses serviceable. This includes frame and lens replacement or replacement of the entire eyeglasses.

F. Eye prosthesis and polishing service require a prior authorization.

242.110Visual Procedure Codes

The following services are covered under the Arkansas Medicaid Program.

Procedure	Required	Coverage
Code	Modifier	Description	Under 21	Over 21
DIAGNOSTIC AND ANCILLARY SERVICES
S0620 S0621	VISION ANALYSIS AND DIAGNOSIS (SINGLE VISION) This service must include the following: case history, general health observation, external exam of the eye and adnexa, ophthalmoscopic examination, determination of refractive state, basic sensorimotor and binocularity examination. It may also include initiation of diagnostic and treatment programs or referral.	yes	yes
92340	FITTING OF SPECTACLES, EXCEPT FOR APHAKIA: MONOFOCAL Fitting includes measurement of anatomical facial characteristics, the writing of laboratory specifications, and the final adjustment of the spectacles to the visual axes and anatomical topography.	yes	yes
99173	UB	PRELIMINARY EVALUATION (MODIFIED SCREENING) This procedure must include at minimum three of the services listed under procedure code V0100. This code may not be billed in conjunction with procedure code V0100.	yes	yes
CONTACT LENS SERVICES
S0592	VISION ANALYSIS AND CONTACT LENS EXAM This service must include the following: biomicroscopy, multiple ophthalmometry, case history, tear flow, measurement of ocular adnexa, initial tolerance evaluation, and may include other tests. This procedure does not include contact lens and should be billed in conjunction with other contact lens procedure codes. If billing this code, DO NOT bill S0620 or S0621. Contacts and glasses may be ordered using this code.	yes W/PA	yes W/PA
S0512	SUPPLYING AND FITTING OF CONTACT LENS (SOFT) Spherical, aphakic, lenticular, toric, hydrophilic (per lens)	yes W/PA	yes W/PA

S0512 -	SUPPLYING AND FITTING OF CONTACT LENS (GAS PERMEABLE) Spherical, aphakic, lenticular, toric, prism ballast (per lens)	yes yes W/PA W/PA
V2501 UA	SUPPLYING AND FITTING OF KERATOCONUS LENS (HARD OR GAS PERMEABLE) - per lens	yes W/PA	yes W/PA
S0512 -	SUPPLYING AND FITTING OF MONOCULAR LENS (HARD OR GAS PERMEABLE)-per lens	yes W/PA	yes W/PA
V2501 U1	SUPPLYING AND FITTING OF MONOCULAR LENS (SOFT LENS) -per lens	yes W/PA	yes W/PA
S0512 -	SUPPLYING AND FITTING OF CONTACT LENS (SOFT) Spherical, aphakic, lenticular, toric, hydrophilic (per lens)	yes W/PA	yes W/PA
LOW VISION SERVICES
92002 UB	LOWVISION EVALUATION	yes W/PA	yes W/PA
SUPPLEMENTAL PROCEDURES
92081 U1	VISUAL FIELD - Electronic or Goldmann	yes	yes
92081 U1	VISUAL FIELD - Confrontation Perimetry	yes	yes
MISCELLANEOUS SERVICES
92100 UB	TONOMETRY This procedure will only be covered when medically necessary. These conditions include, but are not limited to, diabetes, hypertension and age of the patient.	92100	UB
V2623 -	EYE PROSTHESIS Prosthetic eye, plastic, custom	yes W/PA	yes W/PA
V2624 -	POLISHING OF PROSTHESIS Polishing/resurfacing of ocular prosthesis	yes W/PA	yes W/PA
REPAIRS AND MATERIAL SERVICES
V2025 -	FRAME REPLACEMENT This procedure is for professional services only when replacing the whole frame. This procedure may be billed in conjunction with procedure code 92390 (Z0146) for material cost or the material may be ordered through the current optical contractor.	yes	no

PROFESSIONAL SERVICES FOR LENS REPLACEMENT
S0504	RP	LENS REPLACEMENT - SINGLE VISION This procedure is for professional services only. It may be billed in conjunction with procedure code 92390 (Z0146) or through the current optical contractor.	yes	yes W/PA
S0506	RP	LENS REPLACEMENT - BIFOCAL This procedure is for professional services only. It may be billed in conjunction with procedure code 92390 (Z0146) or through the current optical contractor.	yes	yes W/PA
CONTACT LENS REPLACEMENT
92326	"	HARD LENS (PER LENS) This procedure code does not include a professional fee.	yes W/PA	no
92326	"	SOFT LENS (PER LENS) This procedure code does not include a professional fee.	yes W/PA	no
92326	"	GAS PERMEABLE (PER LENS) This procedure code does not include a professional fee.	yes W/PA	no
92396	-	APHAKIC LENS Post-operative cataract.	yes	yes W/PA
92390	SPECTACLE MATERIAL Cost of material for replacing frame, front, temple. This procedure code may be billed in conjunction with V2025 (Z0124), S0504 (Z0134) and S0506 (Z0136). This price may not exceed our maximum rates established with our current optical contractor. When this code is used, an invoice must be attached.	yes	no
V2799	-	UNSPECIFIED PROCEDURE	yes	yes

W/PA = Coverage with prior authorization.

016.06.05 Ark. Code R. 083

3/22/2006