Chapter. CPT only copyright 2010 American Medical Association. All rights reserved. 36Vision Services

Transcription

1 36Vision Services Chapter Enrollment Benefits, Limitations, and Authorization Requirements Frames, Lenses, and Contact Lenses Frames Eyeglass Lenses Special Eyeglass Lenses Contact Lenses Eye Wear Services Requiring Authorization Services Requiring Prior Authorization Eye Prostheses Eye and Vision Examinations Vision Examinations with Refraction Medical Eye Examinations Services Requiring Authorization Special Vision Services Authorization Requirements Ocular Viewing and Diagnostic Testing Procedures Claims Information Reimbursement TMHP-CSHCN Services Program Contact Center CPT only copyright 2010 American Medical Association. All rights reserved.

2 CSHCN Services Program Provider Manual November Enrollment To enroll in the CSHCN Services Program, ophthalmologists, optometrists, and opticians are required to be actively enrolled in Texas Medicaid. They must have a valid Provider Agreement with the CSHCN Services Program, have completed the CSHCN Services Program enrollment process, and comply with all applicable state laws and requirements. Optometrists, ophthalmologists, and opticians may enroll either as an individual or as a group with performing providers. Opticians may also enroll as a facility. Out-of-state ophthalmologist, optometrists, and optician providers must meet all these conditions, and be located in the United States, within 50 miles of the Texas state border. Important: CSHCN Services Program providers are responsible for knowing, understanding, and complying with the laws, administrative rules, and policies of the CSHCN Services Program and Texas Medicaid. By enrolling in the CSHCN Services Program, providers are charged not only with knowledge of the adopted CSHCN Services Program agency rules published in Title 25 Texas Administrative Code (TAC) Chapter 38, but also with knowledge of the adopted Medicaid agency rules published in 1 TAC, Part 15, and specifically including the fraud and abuse provisions contained in Chapter 371. CSHCN Services Program providers also are required to comply with all applicable laws, administrative rules, and policies that apply to their professions or to their facilities. Specifically, it is a violation of program rules when a provider fails to provide health-care services or items to recipients in accordance with accepted medical community standards and standards that govern occupations, as explained in 1 TAC (6) for Medicaid providers, which also applies to CSHCN Services Program providers as set forth in 25 TAC 38.6(b)(1). Accordingly, CSHCN Services Program providers can be subject to sanctions for failure to deliver, at all times, health-care items and services to recipients in full accordance with all applicable licensure and certification requirements. These include, without limitation, requirements related to documentation and record maintenance, such that a CSHCN Services Program provider can be subject to sanctions for failure to create and maintain all records required by his/her profession, as well as those required by the CSHCN Services Program and Texas Medicaid. Refer to: Section 2.1, Provider Enrollment, on page 2-2 for more detailed information about CSHCN Services Program provider enrollment procedures Benefits, Limitations, and Authorization Requirements Vision related services are a benefit of the CSHCN Services Program. The CSHCN Services Program may consider the following services for reimbursement: Vision eye exams with refraction Other eye exams for medical reasons Medical eye treatments Frames Lenses Contact lenses High-power lenses Scleral lenses Repair and replacement of frames and lenses Other vision services The following services are not benefits of the CSHCN Services Program: Eyeglasses that do not significantly improve visual acuity or that do not impede the progression of visual problems Plano sunglasses Optional eyeglass features that are requested by the client but that do not increase visual acuity, such as tinting, decorative accessories or lettering, or eyeglass cases Prisms that are ground into the lenses 36 2 CPT only copyright 2010 American Medical Association. All rights reserved.

3 Vision Services Ultraviolet (UV) lenses (procedure code V2755) Contact lenses that correct color vision deficiency (procedure code V2503) Low vision aids Note: Clients in need of low vision aids may be referred to the Texas Department of Assistive and Rehabilitative Services (DARS) Division for Blind Services (DBS) for consideration of coverage. Vision services are a benefit when provided by ophthalmologists, optometrists, and opticians practicing according to standards established by their licensing boards and the state laws of Texas Frames, Lenses, and Contact Lenses Frames Providers must offer frames that meet the following criteria: A choice of at least three styles that are appropriate to the client s age or gender Frames in sizes that are appropriate to the client s needs A choice of at least three colors Frames must be composed of all zylonite components, meet statutory quality standards, and be made of new materials. Clients or families may only choose frames that are metal or a combination of zylonite and metal if they are willing to pay the difference between the CSHCN Services Program s reimbursement for frames and the cost of metal or metal and zylonite frames. Ophthalmologists, optometrists, and opticians may submit procedure codes V2020 and V2025 for the reimbursement of frames Eyeglass Lenses Lenses must meet the American National Standards Institute (ANSI) specifications (see for first quality prescription ophthalmic lenses, including, but not limited to, the following: Lenses must be made of clear glass or plastic. Lenses must be composed of new materials. Bifocals must be flat-tops or an equivalent style with a near segment of at least 25 mm width. Trifocals must be flat-tops or an equivalent style with an intermediate segment of at least 7 X 25 mm. Ophthalmologists, optometrists, and opticians may submit the following procedure codes for the reimbursement of eyeglass lenses. Providers must bill with a quantity of two for a pair of lenses. Single Vision Lenses Procedure Codes V2100 V2101 V2103 V2104 V2107 V2108 V2115 V2118 V2121 Bifocal Lenses Procedure Codes V2200 V2201 V2203 V2204 V2207 V2208 V2215 V2218 V2219 V2220 V2221 Trifocal Lenses Procedure Codes V2300 V2301 V2303 V2304 V2307 V2308 V2315 V2318 V2319 V2320 V CPT only copyright 2010 American Medical Association. All rights reserved. 36 3

4 CSHCN Services Program Provider Manual November Special Eyeglass Lenses Special lenses, such as high-index, polycarbonate, and high-powered lenses, are a benefit of the CSHCN Services Program if they are ordered by the treating physician because they are medically necessary and not solely because of a client s preference. High-power lenses have a sphere equal to or greater than plus or minus 7 diopters or a cylinder of plus or minus 4 diopters. High-index lenses allow lighter-weight lenses for clients who have unusually heavy lenses. Polycarbonate lenses are considered the standard for children s eyewear because polycarbonate provides extra strength, flexibility, and inherent UV protection. Ophthalmologists, optometrists, and opticians may submit the following procedure codes for the reimbursement of special eyeglass lenses: High-Power Lenses Procedure Codes V2102 V2105 V2106 V2109 V2110 V2111 V2112 V2113 V2114 V2202 V2205 V2206 V2209 V2210 V2211 V2212 V2213 V2214 V2302 V2305 V2306 V2309 V2310 V2311 V2312 V2313 V2314 Special Lenses Procedure Codes V2410 V2430 V2762 V2784 The polarization of lenses (procedure code V2762) prevents damage to the eye from UV rays. The polarization of lenses is a benefit of the CSHCN Services Program for the following diagnosis codes of aphakia: Diagnosis Codes V431 Polycarbonate lens (procedure code V2784) is considered an add-on code and must be billed in conjunction with the primary lens code with the same date of service by the same provider. Polycarbonate lenses provide inherent protection against UV rays; therefore, the polarization of a polycarbonate lens will be denied Contact Lenses Contact lenses that are made of hydrophilic and rigid materials are a benefit of the CSHCN Services Program. Hydrophilic contact lenses that have been reviewed by the U.S. Food and Drug Administration (FDA) and released for sale in the U.S. will be considered for reimbursement only for those uses for which they have been reviewed. Hard and gas permeable lenses must conform to the ANSI requirements for first quality contact lenses. Examinations for contact lens prescriptions and fittings include: The specific optical and physical characteristics of the contact lens including power, size, curvature, flexibility, and gas-permeability. Medically necessary tests including multiple ophthalmometry, measurement of tear flow, measurement of ocular adnexa, and initial tolerance evaluation. The instruction and training of the client and incidental revision during the training period. Follow-up care for a period of six months CPT only copyright 2010 American Medical Association. All rights reserved.

5 Vision Services Ophthalmologists and optometrists may submit the following procedure codes for the fitting of contact lenses: Contact Lens Fitting Exam Procedure Codes Ophthalmologists, optometrists, and opticians may submit the following procedure codes for the reimbursement of contact lenses: Contact Lens Procedure Codes V2500 V2501 V2502 V2510 V2511 V2512 V2513 V2520 V2521 V2522 V2523 V2530 V2531 V2599 Contact lenses and their prescription and fitting are limited to the following diagnosis codes: Retinopathy of prematurity, unspecified Retrolental fibroplasia Retinopathy of prematurity, stage Retinopathy of prematurity, stage Retinopathy of prematurity, stage Hypermetropia 3671 Myopia Unspecified astigmatism Regular astigmatism Irregular astigmatism Anisometropia Aniseikonia 3674 Presbyopia Unspecified amblyopia Strabismic amblyopia Deprivation amblyopia Refractive amblyopia Unspecified keratoconus Keratoconus, stable condition Keratoconus, acute hydrops Aphakia Subluxation of lens Anterior dislocation of lens Posterior dislocation of lens Congenital aphakia Congenital anomaly of corneal size and shape V431 Lens replaced by other means 36 CPT only copyright 2010 American Medical Association. All rights reserved. 36 5

6 CSHCN Services Program Provider Manual November 2011 Contact lenses are sometimes used as corneal bandages to prevent blindness in an eye that is affected by a disease process. Ophthalmologists and optometrists should bill for the fitting of contact lenses for the treatment of disease, which includes the supply of the lens using procedure code in the following way: The provider must document in the medical record that a contact lens used as a corneal bandage was required to treat an acute medical condition. The applicable LT (left eye) or RT (right eye) modifier must be submitted with the claim to indicate which eye was treated. Claims must be submitted with modifier 50 when both eyes are treated. The first procedure may be fully reimbursed, and the second procedure may be reimbursed at half the reimbursement rate. Scleral lenses that are prescribed as a liquid bandage must be billed using procedure code S0515. Scleral lenses that are used therapeutically in other ways should be billed using procedure code V2530 or V2531. Reimbursement for scleral lenses requires authorization. Opticians may bill for the replacement of contact lenses using procedure code If disposable contact lenses are deemed medically necessary and are prior-authorized, procedure code V2599 must be used to bill for their reimbursement Eye Wear The CSHCN Services Program will consider one form of eyewear for reimbursement per calendar year. If a client wants frames or lenses that exceed the benefit limitations, the client must pay the difference between the amount allowed by the CSHCN Services Program and the actual cost. CSHCN Services Program clients or their parents or guardians must acknowledge that their choice exceeds the program requirements by signing the CSHCN Services Program Vision Care Eyeglass Client Certification Form. A copy of this form is provided in Appendix B on page B-120 (English) and on page B-121 (Spanish). Providers must maintain a copy of this signed form in the client s medical record. The provider may withhold the noncovered eyewear until the client pays the difference. If the client fails to pay for the noncovered items within three months, the provider may return any reusable items to stock. Any payment made by the CSHCN Services Program must be refunded to the CSHCN Services Program. More than one pair of eyeglasses may be authorized if there is a change in lens power that is generally equal to or greater than 0.5 diopters in either eye (e.g., progressive myopia, cataract development). Providers may be reimbursed for custom-made eyewear based on the services that were performed and the materials that were used until the time the provider received a notice of cancellation for the eyewear (because the client has died or because the prescription changed before the eyewear was completed and delivered). This applies only to custom items. Items not made to order for a specific client will be denied. One pair of contact lenses and one contact lens prescription and fitting may be covered in a calendar year for a payable diagnosis listed in the table above in Section , Contact Lenses, on page Additional contact lenses and contact lens prescriptions and fittings within the same calendar year may be prior authorized with proof of medical necessity. Contact lenses may require more frequent replacement than one new pair per calendar year, depending on the style and the prescribed use. More frequent replacement must be medically necessary and prior authorization must be obtained. Modification of contact lenses as a separate procedure (procedure code 92325) will be denied as part of another procedure if it is billed with the same date of service by the same provider as contact lens fittings and replacement (procedure codes 92311, 92312, 92313, 92315, 92316, 92317, and 92326). The prescription and fitting of contact lenses for aphakia for both eyes (procedure code 92312) will be denied if it is billed with the same date of service as the prescription and fitting of contact lenses for aphakia for one eye (procedure code 92311) CPT only copyright 2010 American Medical Association. All rights reserved.

7 Vision Services The prescription and fitting of contact lenses for aphakia, the prescription and fitting of corneoscleral lenses, and the modification of contact lenses (procedure codes 92311, 92312, 92313, and 92325) will be denied if they are billed with the same date of service as the replacement of a contact lens (procedure code 92326). The prescription and fitting of contact lenses for aphakia for one eye (procedure code 92311) will be denied if billed with the same date of service as the prescription and fitting of corneoscleral lenses (procedure code 92313) Services Requiring Authorization Authorization is required for medically necessary contact lenses and their prescriptions and fittings for diagnoses that are not listed in the diagnosis table above in Section , Contact Lenses on page Requests for authorization must be submitted using a CSHCN Services Program Authorization and Prior Authorization Request form with documentation of the following: The medical diagnosis of the cause of the disorder of refraction For an established patient, current and new prescriptions that show a change of 0.5d or more in the sphere, cylinder, or prism measurements from a previous exam For a new patient, the new prescription including prescriptive measurements Which eyes are being treated: left, right, or both The specific procedure codes for which the authorization is being requested The medical necessity of contact lenses for the correction of the client s vision or for the treatment of the client s medical condition, and why eyeglasses are inappropriate or contraindicated in this case Authorization is required for scleral lenses (procedure codes V2530 and V2531) and scleral lenses used as liquid bandage devices (procedure code S0515). Providers must submit the CSHCN Services Program Authorization and Prior Authorization Request form. Claims must be submitted with documentation of all of the following: The client has a condition that requires a scleral lens or a liquid bandage and is refractive to conservative treatment. The client has a condition that indicates a severe ocular surface disease, including, but not limited to, the following conditions: Corneal ectasia such as keratoconus, pellucid marginal degeneration, keratoglobus (The use of scleral lenses does not achieve precise vision correction for high-order aberrations related to these diagnoses.) Post keratoplasty astigmatism (Scleral lenses generally provide excellent visual acuity for the treatment of this condition and should be considered in lieu of wedge resections, relaxing incisions, and laser ablations.) Terriens marginal degeneration Corneal surface irregularities that are due to ocular surface disease, anterior corneal dystrophies, scars, and other causes Aphakia, high myopia or astigmatism Corneal stem cell deficiencies that are a result of Stevens-Johnson syndrome and toxic epidermal necrosis (TEN), chemical and thermal injuries, ocular pemphigoid, aniridia, and other causes Keratitis sicca that is a result of disorders of the lacrimal gland such as Sjogren s syndrome, graft vs. host disease, irradiation, surgery, and meibomian gland deficiency Neurotrophic corneas resulting from herpes simplex or zoster keratitis, congenital corneal anesthesia (dysautonomia), diabetes, acoustic neuroma surgery, trigeminal ganglionectomy, trigeminal rhyzotomy, and other causes Persistent noninfectious corneal ulcers and epithelial defects that are associated with stem cell-deficient and neurotrophic corneas 36 CPT only copyright 2010 American Medical Association. All rights reserved. 36 7

8 CSHCN Services Program Provider Manual November 2011 Authorization is not required for the following: One annual vision exam with refraction One medically necessary pair of prescription eyewear per calendar year Eye exams and eye treatments for medical reasons (Medical eye exams and treatments may also include special vision services and ocular viewing and diagnostic procedures.) Refer to: Section 4.2, Authorizations, on page 4-3 for detailed information on prior authorization requirements. Appendix B, CSHCN Services Program Authorization and Prior Authorization Request, on page B Services Requiring Prior Authorization A separate prior authorization request must be submitted for all contact lens replacements and for additional prescriptions and fittings of contact lenses within the calendar year. Requests must be submitted using a CSHCN Services Program Authorization and Prior Authorization Request form in Appendix B on page B-105 with documentation of the following: The medical diagnosis of the cause of the disorder of refraction Which eyes are being treated: left, right, or both The procedure codes for which the prior authorization is being requested The medical necessity of either the replacement of the contact lenses or of an additional contact lens prescription and fitting within the calendar year If a pattern of contact lens replacement is requested, the medical necessity of the pattern of replacement (e.g., monthly, every three months, or any other frequency) for the correction of a client s vision or for the treatment of a client s medical condition must be established. If the request for replacement is because of a change in prescription during the calendar year, the provider must include current and new prescriptions that show a change of 0.5 diopters or more in any corresponding meridian, or a cylinder axis change of at least 20 degrees for a cylinder power of diopters, or a cylinder axis change of at least 15 degree for a cylinder power of diopters, or a cylinder axis change of at least 10 degree for a cylinder power of diopters, or a cylinder axis change of at least 5 degrees for a cylinder power of diopters. Note: A cylinder power of diopters with a change in axis does not warrant replacement glasses. Providers must submit an invoice that shows the manufacturer s suggested retail price (MSRP) of the prescribed contact lenses with the prior authorization request. Procedure code requires prior authorization. The provider must submit the following documentation with their request: The client s diagnosis A clear, concise description of the ophthalmic ultrasound being performed A CPT or HCPCS procedure code which is comparable to the ophthalmic ultrasound being requested The physician s intended fee for this procedure Reason for recommending this particular procedure Note: Services and procedures that are investigational or experimental are not a benefit of the CSHCN Services Program. Refer to: Section 4.3, Prior Authorizations, on page 4-5 for detailed information on prior authorization requirements CPT only copyright 2010 American Medical Association. All rights reserved.

9 Vision Services Eye Prostheses Eye prostheses may be authorized when prescribed by the treating physician and when there is documentation of medical necessity and appropriateness. There are no specific time limitations on replacement of eye prostheses. A child's eye socket may change size at variable times because of differences in bone growth rate and soft tissue change Eye and Vision Examinations Vision services that are medically necessary for the treatment of a client include, but are not limited to, the following: Eye examinations and the treatment of the eye for medical reasons (i.e., aphakia diagnoses, diseases of the eye, or as a result of eye surgery or an injury to the eye). Eye examinations that are performed for medical reasons may be reimbursed as medically necessary. One vision examination with refraction per calendar year to obtain a prescription for eyewear for disorders of refraction and accommodation. More frequent vision exams may be reimbursed if they are recommended by a school nurse, teacher, or parent. One pair of nonprosthetic eyewear per calendar year. A client who experiences vision-related difficulty with activities of daily living (ADLs) or with employment may be referred to DARS DBS for evaluation and appropriate resources Vision Examinations with Refraction Vision examinations with refraction to obtain a prescription for eyewear (procedure code S0620 or S0621) may be reimbursed once per calendar year when billed with one of the following diagnosis codes: 3669 Unspecified cataract 3670 Hypermetropia 3671 Myopia Unspecified astigmatism Regular astigmatism Irregular astigmatism Anisometropia Aniseikonia 3674 Presbyopia Paresis of accommodation Total or complete internal ophthalmoplegia Spasm of accomodation Transient refractive change Other disorder refraction and accommodation 3679 Unspecified disorder of refraction and accommodation Corneal disorder due to contact lens V720 Examination of eyes and vision 36 CPT only copyright 2010 American Medical Association. All rights reserved. 36 9

10 CSHCN Services Program Provider Manual November Medical Eye Examinations Medical eye examinations performed for medical reasons may be reimbursed to ophthalmologists using procedure codes 92002, 92004, 92012, 92014, and These examinations may be reimbursed as medically necessary with a valid 3- to 5-digit diagnosis code that describes the medical reason for the eye examination. Medical eye examinations performed for medical reasons may be reimbursed to optometrists using procedure codes 92002, 92004, 92012, 92014, and These procedure codes are limited to the following diagnosis codes: Herpes zoster dermatitis of eyelid Herpes zoster keratoconjunctivitis Herpes zoster iridocyclitis Other ophthalmic herpes zoster complications Unspecified ophthalmic complication herpes simplex Herpes simplex dermatitis of eyelid Dendritic keratitis Herpes simplex disciform keratitis Herpes simplex iridocyclitis Herpes simplex with other ophthalmic complications 0760 Initial stage trachoma 0761 Active stage trachoma 0769 Unspecified trachoma 0770 Inclusion conjunctivitis 0771 Epidemic keratoconjunctivis 0772 Pharyngoconjunctival fever 0773 Other adenoviral conjunctivitis 0774 Epidemic hemorragic conjunctivitis 0778 Other viral conjunctivitis 0903 Syphilitic interstitial keratitis 0905 Other late congenital syphilis, symptomatic 0906 Late congenital syphilis, latent 0907 Late congenital syphilis, unspecified 0909 Congenital syphilis, unspecified Early syphilis, syphilitic uveitis, unspecified Early syphilis, syphilitic chorioretinitis (secondary) Early syphilis, syphilitic iridocyclitis (secondary) Gonococcal conjunctivitis (neonatorum) Gonococcal iridocyclitis Gonococcal endophthalmia Gonococcal keratitis Other gonococcal infection of eye Histoplasma capsulatum retinitis Histoplasma dubisii retinitis Unspecified Histoplasmosis retinitis CPT only copyright 2010 American Medical Association. All rights reserved.

11 Vision Services Diagnosis Code Description 1301 Conjunctivitis due to toxoplasmosis 1302 Chorioretinitis due to toxoplasmosis 1900 Malignant neoplasm of eyeball, except conjunctiva, cornea, retina, and choroid 1901 Malignant neoplasm of orbit 1902 Malignant neoplasm of lacrimal gland 1903 Malignant neoplasm of conjunctiva 1904 Malignant neoplasm of cornea 1905 Malignant neoplasm of retina 1906 Malignant neoplasm of choroid 1907 Malignant neoplasm of lacrimal duct 1908 Malignant neoplasm of other specified sites of eye 1909 Malignant neoplasm of eye, part unspecified 2240 Benign neoplasm of eyeball, except conjunctiva, cornea, retina, and choroid 2241 Benign neoplasm of orbit 2242 Benign neoplasm of lacrimal gland 2243 Benign neoplasm of conjunctiva 2244 Benign neoplasm of cornea 2245 Benign neoplasm of retina 2246 Benign neoplasm of choroid 2247 Benign neoplasm of lacrimal duct 2248 Benign neoplasm of other specified parts of eye 2249 Benign neoplasm of eye, part unspecified 2340 Carcinoma in situ of eye Neoplasms of unspecified nature, retina and choroid Secondary diabetes mellitus without mention of complication, not stated as, or unspecified Secondary diabetes mellitus without mention of complication, Secondary diabetes mellitus with ketoacidosis, not stated as, or unspecified Secondary diabetes mellitus with ketoacidosis, Secondary diabetes mellitus with hyperosmolarity, not stated as, or unspecified Secondary diabetes mellitus with hyperosmolarity, Secondary diabetes mellitus with other coma, not stated as, or unspecified Secondary diabetes mellitus with other coma, Secondary diabetes mellitus with renal manifestations, not stated as, or unspecified Secondary diabetes mellitus with renal manifestations, Secondary diabetes mellitus with ophthalmic manifestations, not stated as, or unspecified Secondary diabetes mellitus with ophthalmic manifestations, 36 CPT only copyright 2010 American Medical Association. All rights reserved

12 CSHCN Services Program Provider Manual November 2011 Diagnosis Code Description Secondary diabetes mellitus with neurological manifestations, not stated as, or unspecified Secondary diabetes mellitus with neurological manifestations, Secondary diabetes mellitus with peripheral circulatory disorders, not stated as, or unspecified Secondary diabetes mellitus with peripheral circulatory disorders, Secondary diabetes mellitus with other specified manifestations, not stated as, or unspecified Secondary diabetes mellitus with other specified manifestations, Secondary diabetes mellitus with unspecified complication, not stated as, or unspecified Secondary diabetes mellitus with unspecified complication, Diabetes mellitus without mention of complication, type II or unspecified type, not stated as Diabetes mellitus without mention of complication, type I (juvenile type), not stated as Diabetes mellitus without mention of complication, type II or unspecified type, Diabetes mellitus without mention of complication, type I (juvenile type), Diabetes with ketoacidosis, type II or unspecified type, not stated as Diabetes with ketoacidosis, type I (juvenile type), not stated as Diabetes with ketoacidosis, type II or unspecified type, Diabetes with ketoacidosis, type I (juvenile type), Diabetes with hyperosmolarity, type II or unspecified type, not stated as Diabetes with hyperosmolarity, type I (juvenile type), not stated as Diabetes with hyperosmolarity, type II or unspecified type, Diabetes with hyperosmolarity, type I (juvenile type), Diabetes with other coma, type II or unspecified type, not stated as Diabetes with other coma, type I (juvenile type), not stated as Diabetes with other coma, type II or unspecified type, Diabetes with other coma, type I (juvenile type), Diabetes with renal manifestations, type II or unspecified type, not stated as Diabetes with renal manifestations, type I (juvenile type), not stated as Diabetes with renal manifestations, type II or unspecified type, Diabetes with renal manifestations, type I (juvenile type), Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as CPT only copyright 2010 American Medical Association. All rights reserved.

13 Vision Services Diagnosis Code Description Diabetes with ophthalmic manifestations, type I (juvenile type), not stated as Diabetes with ophthalmic manifestations, type II or unspecified type, Diabetes with ophthalmic manifestations, type I (juvenile type), Diabetes with neurological manifestations, type II or unspecified type, not stated as Diabetes with neurological manifestations, type I (juvenile type), not stated as Diabetes with neurological manifestations, type II or unspecified type, Diabetes with neurological manifestations, type I (juvenile type), Diabetes with peripheral circulatory disorders, type II or unspecified type, not stated as Diabetes with peripheral circulatory disorders, type I (juvenile type), not stated as Diabetes with peripheral circulatory disorders, type II or unspecified type, Diabetes with peripheral circulatory disorders, type I (juvenile type), Diabetes with other specified manifestations, type II or unspecified type, not stated as Diabetes with other specified manifestations, type I (juvenile type), not stated as Diabetes with other specified manifestations, type II or unspecified type, Diabetes with other specified manifestations, type I (juvenile type), Diabetes with unspecified complication, type II or unspecified type, not stated as Diabetes with unspecified complication, type I (juvenile type), not stated as Diabetes with unspecified complication, type II or unspecified type, Diabetes with unspecified complication, type I (juvenile type), Unspecified purulent endophthalmitis Acute endophthalmitis Panophthalmitis Chronic endophthalmitis Vitreous abscess Sympathetic uveitis Panuveitis Parasitic endophthalmitis NOS Parasitic endophthalmitis NOS Other endophthalmitis Unspecified degenerative disorder of globe 36 CPT only copyright 2010 American Medical Association. All rights reserved

14 CSHCN Services Program Provider Manual November Progressive high (degenerative) myopia Siderosis of globe Other metallosis of globe Other degenerative disorders of globe Unspecified hypotony of eye Primary hypotony of eye Ocular fistula causing hypotony Hypotony associated with other ocular disorders Flat anterior chamber of eye Unspecified degenerated globe or eye Blind hypotensive eye Blind hypertensive eye Hemophthalmos, except current injury Leucocoria Retained (old) foreign body, magnetic, intraocular, unspecified Retained (old) foreign body, magnetic, in anterior chamber of eye Retained (old) foreign body, magnetic, in iris or ciliary body Retained (old) foreign body, magnetic, in lens Retained (old) foreign body, magnetic, in vitreous Retained (old) foreign body, magnetic, in posterior wall Retained (old) intraocular foreign body, magnetic, in other or multiple sites Retained (old) foreign body, intraocular, unspecified Retained (old) foreign body in anterior chamber Retained (old) foreign body in iris or ciliary body Retained (old) foreign body in lens Retained (old) foreign body in vitreous Foreign body in posterior wall of eye Retained (old) foreign body in other or multiple sites of eye Luxation of globe Other disorders of globe 3609 Unspecified disorder of globe Retinal detachment with retinal defect, unspecified Recent retinal detachment, partial, with single defect Recent retinal detachment, partial, with multiple defects Recent retinal detachment, partial, with giant tear Recent retinal detachment, partial, with retinal dialysis Recent retinal detachment, total or subtotal Old retinal detachment, partial Old retinal detachment, total or subtotal Unspecified retinoschisis Flat retinoschisis CPT only copyright 2010 American Medical Association. All rights reserved.

15 Vision Services Bullous retinoschisis Primary retinal cysts Secondary retinal cysts Other retinoschisis and retinal cysts 3612 Serous retina detachment Unspecified retinal defect Round hole of retina without detachment Horseshoe tear of retina without detachment Multiple defects of retina without detachment Traction detachment of retina Other forms of retinal detachment 3619 Unspecified retinal detachment Background diabetic retinopathy Proliferative diabetic retinopathy Nonproliferative diabetic retinopathy NOS Mild nonproliferative diabetic retinopathy Moderate nonproliferative diabetic retinopathy Severe nonproliferative diabetic retinopathy Diabetic macular edema Unspecified background retinopathy Hypertensive retinopathy Exudative retinopathy Changes in vascular appearance of retina Retinal microaneurysms NOS Retinal telangiectasia Retinal neovascularization NOS Other intraretinal microvascular abnormalities Retinal vasculitis Retinopathy of prematurity, unspecified Retrolental fibroplasia Retinopathy of prematurity, stage Retinopathy of prematurity, stage Retinopathy of prematurity, stage Retinopathy of prematurity, stage Retinopathy of prematurity, stage Retinopathy of prematurity, stage Other nondiabetic proliferative retinopathy Unspecified retinal vascular occlusion Central artery occlusion of retina Arterial branch occlusion of retina Partial arterial occlusion of retina 36 CPT only copyright 2010 American Medical Association. All rights reserved

16 CSHCN Services Program Provider Manual November Transient arterial occlusion of retina Central vein occlusion of retina Venous tributary (branch) occlusion of retina Venous engorgement of retina Unspecified retinal layer separation Serous detachment of retinal pigment epithelium Hemorrhagic detachment of retinal pigment epithelium Macular degeneration (senile) of retina, unspecified Nonexudative senile macular degeneration of retina Exudative senile macular degeneration of retina Cystoid macular degeneration of retina Macular cyst, hole, or pseudohole of retina Toxic maculopathy of retina Macular puckering of retina Drusen (degenerative) of retina Unspecified peripheral retinal degeneration Paving stone degeneration of peripheral retina Microcystoid degeneration of peripheral retina Lattice degeneration of peripheral retina Senile reticular degeneration of peripheral retina Secondary pigmentary degeneration of peripheral retina Secondary vitreoretinal degenerations of peripheral retina Plateau iris syndrome Total or complete internal ophthalmoplegia Spasm of accommodation Other disorders of refraction and accommodation Unspecified amblyopia Strabismic amblyopia Deprivation amblyopia Refractive amblyopia Unspecified subjective visual disturbance Sudden visual loss Transient visual loss Visual discomfort Visual distortions of shape and size Other visual distortions and entoptic phenomena Psychophysical visual disturbances 3682 Diplopia Unspecified binocular vision disorder Suppression of binocular vision Simultaneous visual perception without fusion CPT only copyright 2010 American Medical Association. All rights reserved.

17 Vision Services Diagnosis Code Description Fusion with defective stereopsis Abnormal retinal correspondence Unspecified visual field defect Cotoma involving central area in visual field Scotoma of blind spot area in visual field Sector or arcuate visual field defects in visual field Other localized visual field defect Generalized visual field contraction or constriction in visual field Homonymous bilateral field defects in visual field Heteronymous bilateral field defects in visual field Protan defect in color vision Deutan defect in color vision Tritan defect in color vision Achromatopsia Acquired color vision deficiencies Other color vision deficiencies Unspecified night blindness Congenital night blindness Acquired night blindness Abnormal dark adaptation curve Other night blindness 3688 Other specified visual disturbances 3689 Unspecified visual disturbance Blindness of both eyes, impairment level not further specified Better eye: total vision impairment; lesser eye: total vision impairment Better eye: near-total vision impairment; lesser eye: not further specified Better eye: near-total vision impairment; lesser eye: total vision impairment Better eye: near-total vision impairment; lesser eye: near-total vision impairment Better eye: profound vision impairment; lesser eye: not further specified Better eye: profound vision impairment; lesser eye: total vision impairment Better eye: profound vision impairment; lesser eye: near-total vision impairment Better eye: profound vision impairment; lesser eye: profound vision impairment Profound, moderate or severe vision impairment, not further specified Better eye: severe vision impairment; lesser eye: blind, not further specified Better eye: severe vision impairment; lesser eye: total vision impairment Better eye: severe vision impairment; lesser eye: near-total vision impairment Better eye: severe vision impairment; lesser eye: profound vision impairment Better eye: moderate vision impairment; lesser eye: blind, not further specified Better eye: moderate vision impairment; lesser eye: total vision impairment 36 CPT only copyright 2010 American Medical Association. All rights reserved

18 CSHCN Services Program Provider Manual November 2011 Diagnosis Code Description Better eye: moderate vision impairment; lesser eye: near-total vision impairment Better eye: moderate vision impairment; lesser eye: profound vision impairment Vision impairment, both eyes, impairment level not further specified Better eye: severe vision impairment; lesser eye; impairment not further specified Better eye: severe vision impairment; lesser eye: severe vision impairment Better eye: moderate vision impairment; lesser eye: impairment not further specified Better eye: moderate vision impairment; lesser eye: severe vision impairment Better eye: moderate vision impairment; lesser eye: moderate vision impairment 3693 Unqualified visual loss, both eyes 3694 Legal blindness, as defined in USA Blindness, one eye, not otherwise specified One eye: total vision impairment; other eye: not specified One eye: total vision impairment; other eye: near-normal vision One eye: total vision impairment; other eye: normal vision One eye: near-total vision impairment; other eye: vision not specified One eye: near-total vision impairment; other eye: near-normal vision One eye: near-total vision impairment; other eye: normal vision One eye: profound vision impairment; other eye: vision not specified One eye: profound vision impairment; other eye: near-normal vision One eye: profound vision impairment; other eye: normal vision Low vision, one eye, not otherwise specified One eye: severe vision impairment; other eye: vision not specified One eye: severe vision impairment; other eye: near-normal vision One eye: severe vision impairment; other eye: normal vision One eye: moderate vision impairment; other eye: vision not specified One eye: moderate vision impairment; other eye: near-normal vision One eye: moderate vision impairment; other eye: normal vision 3698 Unqualified visual loss, one eye 3699 Unspecified visual loss Unspecified corneal ulcer Marginal corneal ulcer Ring corneal ulcer Central corneal ulcer Hypopyon ulcer Mycotic corneal ulcer Perforated corneal ulcer Mooren's ulcer Unspecified superficial keratitis CPT only copyright 2010 American Medical Association. All rights reserved.

19 Vision Services Punctate keratitis Macular keratitis Filamentary keratitis Photokeratitis Phlyctenular keratoconjunctivitis Limbar and corneal involvement in vernal conjunctivitis Keratoconjunctivitis sicca, not specified as Sjogren's Exposure keratoconjunctivitis Neurotrophic keratoconjunctivitis Unspecified keratoconjunctivitis Keratitis or keratoconjunctivitis in exanthema Other unspecified keratoconjunctivitis Unspecified interstitial keratitis Diffuse interstitial keratitis Sclerosing keratitis Corneal abscess Other interstitial and deep keratitis Unspecified corneal neovascularization Localized vascularization of cornea Pannus (corneal) Deep vascularization of cornea Ghost vessels (corneal) in corneal neovascularization 3708 Other forms of keratitis 3709 Unspecified keratitis Unspecified corneal opacity, Minor opacity of cornea Peripheral opacity of cornea Central opacity of cornea Adherent leucoma Phthisical cornea Unspecified corneal deposit Anterior pigmentations of cornea Stromal pigmentations of cornea Posterior pigmentations of cornea Kayser-Fleischer ring Other corneal deposits associated with metabolic disorders Argentous corneal deposits Unspecified corneal edema Idiopathic corneal edema Secondary corneal edema Bullous keratopathy 36 CPT only copyright 2010 American Medical Association. All rights reserved

20 CSHCN Services Program Provider Manual November Corneal edema due to wearing of contact lenses Unspecified corneal membrane change Folds and rupture of Bowman's membrane Folds in Descemet's membrane Rupture in Descemet's membrane Unspecified corneal degeneration Senile corneal changes Recurrent erosion of cornea Band-shaped keratopathy Other calcerous degenerations of cornea Keratomalacia NOS Nodular degeneration of cornea Peripheral degenerations of cornea Corneal degenerations, Other Unspecified hereditary corneal dystrophy Juvenile epithelial corneal dystrophy Other anterior corneal dystrophies Granular corneal dystrophy Lattice corneal dystrophy Macular corneal dystrophy Other stromal corneal dystrophies Endothelial corneal dystrophy Other posterior corneal dystrophies Unspecified keratoconus Keratoconus, stable condition Keratoconus, acute hydrops Unspecified corneal deformity Corneal ectasia Descemetocele Corneal staphyloma Corneal anesthesia and hypoesthesia Corneal disorder due to contact lens Other corneal disorders 3719 Unspecified corneal disorder Unspecified acute conjunctivitis Serous conjunctivitis, except viral Acute follicular conjunctivitis Other mucopurulent conjunctivitis Pseudomembranous conjunctivitis Acute atopic conjunctivitis Acute chemical conjunctivitis CPT only copyright 2010 American Medical Association. All rights reserved.

21 Vision Services Unspecified chronic conjunctivitis Simple chronic conjunctivitis Chronic follicular conjunctivitis Vernal conjunctivitis Other chronic allergic conjunctivitis Parasitic conjunctivitis Unspecified blepharoconjunctivitis Angular blepharoconjunctivitis Contact blepharoconjunctivitis Unspecified conjunctivitis Rosacea conjunctivitis Conjunctivitis in mucocutaneous disease Pingueculitis Other and unspecified conjunctivitis Unspecified pterygium Peripheral pterygium, stationary Peripheral pterygium, progressive Central pterygium Double pterygium Recurrent pterygium Unspecified conjunctival degeneration Pinguecula Pseudopterygium Conjunctival xerosis Conjunctival concretions Conjunctival pigmentations Conjunctival deposits Granuloma of conjunctiva Localized adhesions and strands of conjunctiva Symblepharon Scarring of conjunctiva Hyperemia of conjunctiva Conjunctival hemorrhage Conjunctival edema Vascular abnormalities of conjunctiva Conjunctival cysts Conjunctivochalasis Other disorders of conjunctiva 3729 Unspecified disorder of conjunctiva Blepharitis, unspecified Ulcerative blepharitis 36 CPT only copyright 2010 American Medical Association. All rights reserved

22 CSHCN Services Program Provider Manual November Squamous blepharitis Hordeolum externum Hordeolum internum Abscess of eyelid 3732 Chalazion Eczematous dermatitis of eyelid Contact and allergic dermatitis of eyelid Xeroderma of eyelid Discoid lupus erythematosus of eyelid 3734 Infective dermatitis of eyelid of types resulting in deformity 3735 Other infective dermatitis of eyelid 3736 Parasitic infestation of eyelid 3738 Other inflammations of eyelids 3739 Unspecified inflammation of eyelid Unspecified entropion Senile entropion Mechanical entropion Spastic entropion Cicatricial entropion Trichiasis of eyelid without entropion Unspecified ectropion Senile ectropion Mechanical ectropion Spastic ectropion Cicatricial ectropion Unspecified lagophthalmos Paralytic lagophthalmos Mechanical lagophthalmos Cicatricial lagophthalmos Unspecified ptosis of eyelid Paralytic ptosis Myogenic ptosis Mechanical ptosis Blepharochalasis Lid retraction or lag Abnormal innervation syndrome of eyelid Sensory disorders of eyelid Other sensorimotor disorders of eyelid Blepharophimosis Unspecified degenerative disorder of eyelid Xanthelasma of eyelid CPT only copyright 2010 American Medical Association. All rights reserved.