Transcription
NEW YORK STATEMEDICAID PROGRAMVISION CAREPROCEDURE CODES
Vision Care Procedure CodesTable of ContentsGENERAL INFORMATION AND INSTRUCTIONS . 3MMIS MODIFIERS. 4EVALUATION AND MANAGEMENT SERVICES DEFINITIONS . 6SERVICES SECTION . 13GENERAL INFORMATION AND RULES . 13EVALUATION AND MANAGEMENT CODES . 14OPHTHALMOLOGICAL DIAGNOSTIC AND TREATMENT SERVICES . 17SURGERY SECTION . 22GENERAL INFORMATION AND RULES . 23EYE AND OCULAR ADNEXA CODES . 23MATERIALS SECTION . 23GENERAL INFORMATION AND RULES . 24CODES . 24LOW VISION AIDS . 26Version 2022Page 2 of 27
Vision Care Procedure CodesGENERAL INFORMATION AND INSTRUCTIONS1. Fee Schedule: The fees listed in the Vision Care Fee Schedule, available e/index.html, apply to self- employed andsalaried optometrists, dispensing opticians and retail optical establishments and are themaximum reimbursable Medicaid fees. Ophthalmologists cannot bill using this Manual.2. Multiple Calls: If an individual patient is seen on more than one occasion during a single day,the fee for each visit may be allowed.3. Charges for Diagnostic Procedures: Charges for special diagnostic procedures which arenot considered to be a routine part of an attending optometrist’s examination or visit (e.g.,gonioscopy, extended ophthalmoscopy) are reimbursable in addition to the usual optometrist’svisit fee.4. Referral: A referral is the transfer of the total or specific care of a patient from one practitionerto another and does not constitute a consultation. Initial evaluation and subsequent servicesare designated as listed in LEVELS of E/M SERVICE.5. Consultation: Consultation is to be distinguished from referral. REFERRAL is the transfer ofthe patient from one practitioner to another for definitive treatment. CONSULTATION is adviceand opinion from an optometry specialist called in by the attending practitioner in regard to thefurther management of the patient by the attending practitioner.Consultation fees are applicable only when examinations are provided by an optometryspecialist within the scope of his specialty upon request of the attending practitioner who istreating the medical problem for which consultation is required. The attending practitioner mustcertify that he requested such consultation and that it was incident and necessary to his furthercare of the patient.When the consultant optometrist assumes responsibility for a portion of patient management,he will be rendering concurrent care (use appropriate level of Evaluation and Managementcodes). If he has had the case transferred or referred to him, he should then use theappropriate codes for services rendered (e.g., visits, procedures) on and subsequent to thedate of transfer.Version 2022Page 3 of 27
Vision Care Procedure Codes6. By Report: A service that is rarely provided, unusual, variable, or new may require a specialreport in determining clinical appropriateness of the service, indicated by a “BR” in the FeeSchedule. Pertinent information should include an adequate definition or description of thenature, extent, and need for the procedure, and the time, effort and equipment necessary toprovide the service. Additional items which may be included are: complexity of symptoms, finaldiagnosis, pertinent physical findings (such as size, locations, and number of lesion(s), ifappropriate), diagnostic and therapeutic procedures (including major and supplementarysurgical procedures, if appropriate), concurrent problems, and follow-up care.When the value of a procedure is to be determined “By Report” (BR), information concerningthe nature, extent and need for the procedure or service must be furnished in addition to thetime, skill and equipment necessitated. Appropriate documentation (e.g., proceduredescription, itemized invoices, etc.) should accompany all claims submitted.Itemized invoices must document acquisition cost, the line item cost from a manufacturer orwholesaler net of any rebates, discounts or other valuable considerations.7. Payment in Full: Fees paid in accordance with the allowances in the New York State VisionCare Fee Schedule shall be considered full payment for services rendered. No additionalcharge shall be made by a provider.8. Separate Procedure: Certain of the listed procedures are commonly carried out as an integralpart of a total service and as such do not warrant a separate charge. When such a procedureis carried out as a separate entity, not immediately related to other services, the indicatedvalue for “Separate Procedure” is applicable.9. Prior Approval: Payment for those listed procedures where the procedure code number isunderlined is dependent upon obtaining the approval of the Department of Health prior toperformance of the procedure. If such prior approval is not obtained, no reimbursement will bemade.10. Low Vision Services: Low vision examination, low vision aids and fitting of low vision aids arereimbursable to self-employed optometrists specifically certified by the New York StateOptometric Association to perform low vision examinations. (Code W0021 has been deleted.To report low vision examination, use codes 92002-92014.)MMIS MODIFIERSUnder certain circumstances, the procedure code identifying a specific procedure or service must beexpanded by two additional characters to further define or explain the nature of the procedure.The circumstances under which such further description is required are detailed below along with theappropriate modifiers to be added to the basic code when the particular circumstance applies.Version 2022Page 4 of 27
Vision Care Procedure Codes-LT (Left Side): (Used to identify procedures performed on the left side of the body)Add modifier –LT to the usual procedure code number. (Reimbursement will not exceed 100% of themaximum State Medical Fee Schedule amount. One claim line should be billed.)-RP (Replacement), valid for dates of service through 3/31/2009: Replacement of lost or destroyedeyeglasses may be reported by adding the modifier –RP to the eyeglass material codes and the fittingcode.-RB (Replacement), valid for dates of service on or after 4/1/2009: Replacement of lost, destroyed orbroken eyeglasses may be reported by adding the modifier –RB to the eyeglass material codes andthe fitting code.-RT (Right Side): (Used to identify procedures performed on the right side of the body)Add modifier –RT to the usual procedure code number. (Reimbursement will not exceed 100% of themaximum State Medical Fee Schedule amount. One claim line should be billed.)Version 2022Page 5 of 27
Vision Care Procedure CodesEVALUATION AND MANAGEMENT SERVICES DEFINITIONS1. CLASSIFICATION OF EVALUATION AND MANAGEMENT (E/M) SERVICES: The FederalHealth Care Finance Administration has mandated that all state Medicaid programs utilize theEvaluation and Management coding as published in the American Medical Association’sPhysicians’ Current Procedural Terminology for services covered by the program.The E/M section is divided into broad categories such as office visits and consultations. Mostof the categories are further divided into two or more subcategories of E/M services. Forexample, there are two subcategories of office visits (new patient and established patient). Thesubcategories of E/M services are further classified into levels of E/M services that areidentified by specific codes. This classification is important because the nature of optometrywork varies by type of service, place of service, and the patient’s status.The basic format of the levels of E/M services is the same for most categories. First, a uniquecode number is listed. Second, the place and/or type of service is specified, e.g., officeconsultation. Third, the content of the service is defined, e.g., comprehensive history andcomprehensive examination. (See levels of E/M services following for details on the content ofE/M services.) Fourth, the nature of the presenting problem(s) usually associated with a givenlevel is described. Fifth, the time typically required to provide the service is specified.2. DEFINITIONS OF COMMONLY USED E/M TERMS: Certain key words and phrases are usedthroughout the E/M section. The following definitions are intended to reduce the potential fordiffering interpretations and to increase the consistency of reporting.CHIEF COMPLAINT: A concise statement describing the symptom, problem, condition,diagnosis or other factor that is the reason for the encounter, usually stated in the patient’swords.CONCURRENT CARE: Is the provision of similar services, e.g., visits, to the same patient bymore than one practitioner on the same day. When concurrent care is provided, no specialreporting is required.COUNSELING: Counseling is a discussion with a patient and/or family concerning one ormore of the following areas: diagnostic results, impressions, and/or recommended diagnostic studies; prognosis; risks and benefits of management (treatment) options; instructions for management (treatment) and/or follow-up; importance of compliance with chosen management (treatment) options; risk factor reduction; and patient and family education.Version 2022Page 6 of 27
Vision Care Procedure CodesFAMILY HISTORY: A review of medical events in the patient’s family that includes significantinformation about: the health status or cause of death of parents, siblings, and children; specific diseases related to problems identified in the Chief Complaint or History of thePresent Illness, and/or System Review; diseases of family members which may be hereditary or place the patient at risk.HISTORY OF PRESENT ILLNESS: A chronological description of the development of thepatient’s present illness from the first sign and/or symptom to the present. This includes adescription of location, quality, severity, timing, context, modifying factors and associated signsand symptoms significantly related to the presenting problem(s).NATURE OF PRESENTING PROBLEM: A presenting problem is a disease, condition, illness,injury, symptom, sign, finding, complaint, or other reason for encounter, with or without adiagnosis being established at the time of the encounter. The E/M codes recognize five typesof presenting problems that are defined as follows: Minimal – A problem that requires the least intense level of intervention by theoptometrist. Self-limited or Minor – A problem that runs a definite and prescribed course, is transientin nature and is not likely to permanently alter health status OR has a good prognosiswith management/compliance. Low severity – A problem where the risk of morbidity without treatment is low; there islittle to no risk of mortality without treatment; full recovery without functional impairmentis expected. Moderate severity – A problem where the risk of morbidity without treatment ismoderate; there is moderate risk of mortality without treatment; uncertain prognosis ORincreased probability of prolonged functional impairment. High severity – A problem where the risk of morbidity without treatment is high toextreme; there is a moderate to high risk of mortality without treatment OR highprobability of severe, prolonged functional impairment.NEW AND ESTABLISHED PATIENT: A new patient is one who has not received anyprofessional services from the optometrist within the past three years.An established patient is one who has received professional services from the optometristwithin the past three years and whose medical and administrative records are available to theoptometrist.In the instance where an optometrist is on call for or covering for another optometrist, thepatient’s encounter will be classified as it would have been by the optometrist who is notavailable.PAST HISTORY: A review of the patient’s past experiences with illnesses, injuries, andtreatments that include significant information about:Version 2022Page 7 of 27
Vision Care Procedure Codes prior major illnesses and injuries;prior operations;prior hospitalizations;current medications;allergies (e.g., drug, food);age appropriate immunization status;age appropriate feeding/dietary status;SOCIAL HISTORY: an age appropriate review of past and current activities that includesignificant information about: marital status and/or living arrangements; current employment; occupational history; use of drugs, alcohol, and tobacco; level of education; sexual history; other relevant social factors.SYSTEM REVIEW (REVIEW OF SYSTEMS): An inventory of body systems obtained througha series of questions seeking to identify signs and/or symptoms which the patient may beexperiencing or has experienced. The following elements of a system review have beenidentified: Constitutional symptoms Integumentary(fever, weight loss, etc.)(skin and/or breast) Musculoskeletal Eyes Neurological Ears, Nose, Mouth, Throat Cardiovascular Psychiatric Respiratory Endocrine Gastrointestinal Hematologic/Lymphatic Genitourinary Allergic/ImmunologicThe review of systems helps define the problem, clarify the differential diagnoses , identifyneeded testing, or serves as baseline data on other systems that might be affected by anypossible management options.TIME: The inclusion of time in the definitions of levels of E/M services has been implicit in prioreditions. The inclusion of time as an explicit factor beginning in 1992 is done to assist optometristin selecting the most appropriate level of E/M services. Beginning with CPT 2021, except for99211, time alone may be used to select the appropriate code level for the office or otheroutpatient E/M service codes (99202,99203,99204,99205,99212,99214,99215). Differentcategories of services use time differently. It is important to review the instructions for eachcategoryIntra-service times are defined as face-to-face time for office visits.Version 2022Page 8 of 27
Vision Care Procedure CodesA. Face-to-face time (e.g., office visits, office consultations): For coding purposes, faceto-face time for these services is defined as only that time the optometrist spends face-toface with the patient and/or family. This includes the time in which the optometrist performssuch tasks as obtaining a history, performing an examination, and counseling the patient.Optometrists also spend time doing work before or after face-to-face time with the patient,performing such tasks as reviewing records and tests, arranging for further services, andcommunicating further with other professionals and the patient through written reports andtelephone contact.This non face-to-face time for office services – also called pre- and post-encounter time – isnot included in the time component described in the E/M codes. However, the pre- and postface-to-face work associated with an encounter was included in calculating the total work oftypical services.Thus, the face-to-face time associated with the services described by any E/M code is avalid proxy for the total work done before, during, and after the visit.3. A. LEVELS OF E/M SERVICES: Within each category or subcategory of E/M service, there aretwo to three levels of E/M services available for reporting purposes. Levels of E/M services are notinterchangeable among the different categories or subcategories of service. For example, the firstlevel of E/M services in the subcategory of office visit, new patient, does not have the samedefinition as the first level of E/M services in the subcategory of office visit, established patient.The levels of E/M services include examinations, evaluations, treatments, conferences with orconcerning patients, preventive pediatric and adult health supervision, and similar medicalservices such as the determination of the need and/or location for appropriate care.Medical screening includes the history, examination, and medical decision-making required todetermine the need and/or location for appropriate care and treatment of the patient. The levels ofE/M services encompass the wide variations in skill, effort, time, responsibility and medicalknowledge required for the prevention or diagnosis and treatment of illness or injury and thepromotion of optimal health.The descriptors for the levels of E/M services recognize seven components, six of which are usedin defining the levels of E/M services. These components are: history; examination, medicaldecision making, counseling; coordination of care; nature of presenting problem, and time.The first three of these components (history, examination and medical decision making) areconsidered the key components in selecting a level of E/M services.The next three components (counseling, coordination of care, and the nature of the presentingproblem) are considered contributory factors in the majority of encounters. Although the first twoof these contributory factors are important E/M services, it is not required that these services beprovided at every patient encounter. The final component, time, has already been discussed indetail.Version 2022Page 9 of 27
Vision Care Procedure CodesThe actual performance of diagnostic tests/studies for which specific codes are available is notincluded in the levels of E/M services. Optometrist performance of diagnostic tests/studies forwhich specific codes are available should be reported separately, in addition to the appropriateE/M code.3. B. INSTRUCTIONS FOR SELECTING A LEVEL OF E/M SERVICE:i.IDENTIFY THE CATEGORY AND SUBCATEGORY OF SERVICE: Select from thecategories and subcategories of codes available for reporting E/M services.ii.REVIEW THE REPORTING INSTRUCTIONS FOR THE SELECTED CATEGORY ORSUBCATEGORY: Most of the categories and many of the subcategories of servicehave special guidelines or instructions unique to that category or subcategory.iii.REVIEW THE LEVEL OF E/M SERVICE DESCRIPTIORS AND EXAMPLES IN THESELECTED CATEGORY OR SUBCATEGORY: The descriptors for the levels of E/Mservices recognize seven components, six of which are used in defining the levels ofE/M services. These components are: history, examination, medical decision making,counseling, coordination of care, nature of presenting problem, and time.The first three of these components (i.e., history, examination and medical decision making) shouldbe considered the key components in selecting the level of E/M services. An exception to this rule isin the case of visits which consist predominantly of counseling or coordination of care (see vii.C.).The nature of the presenting problem and time are provided in some levels to assist the optometrist indetermining the appropriate level of E/M service.iv.DETERMINE THE EXTENT OF HISTORY OBTAINED: The levels of E/M servicesrecognize four types of history that are defined as follows: Problem Focused – chief complaint, brief history of present illness or problem. Expanded Problem Focused – chief complaint; brief history of present illness;problem pertinent system review. Detailed – chief complaint; extended history of present illness; problem pertinentsystem review extended to include review of a limited number of additionalsystems; pertinent past, family and/or social history directly related to thepatient’s problems. Comprehensive – chief complaint; extended history of present illness; review ofsystems which is directly related to the problem(s) identified in the history of thepresent illness plus a review of all additional body systems; complete past, familyand social history.The comprehensive history obtained as part of the preventive medicine evaluation and managementservice is not problem-oriented and does not involve a chief complaint of present illness. It does,however, include a comprehensive system review and comprehensive or interval past, family andsocial history as well as a comprehensive assessment/history of pertinent risk factors.Version 2022Page 10 of 27
Vision Care Procedure Codesv.DETERMINE THE EXTENT OF EXAMINATION PERFORMED: The levels of E/Mservices recognize four types of examination that are defined as follows: Problem Focused – a limited examination of the affected body area or organsystem. Expanded Problem Focused – a limited examination of the affected body area ororgan system and other symptomatic or related organ system(s). Detailed – an extended examination of the affected body area(s) and othersymptomatic or related organ system(s). Comprehensive – a general multi-system examination or a complete examinationof a single organ system.For the purpose of these definitions, the following body areas are recognized: head, including theface; neck; chest, including breasts and axilla; abdomen; genitalia, groin, buttocks; back and eachextremity.vi.DETERMINE THE COMPLEXITY OF MEDICAL DECISION MAKING: Medical decisionmaking refers to the complexity of establishing a diagnosis and/or selecting amanagement option as measured by: the number of possible diagnoses and/or the number of management options thatmust be considered;the amount and/or complexity of optometric records, diagnostic tests, and/or otherinformation that must be obtained, reviewed and analyzed; andthe risk of significant complications, morbidity and/or mortality, as well as comorbidities, associated with the patient’s presenting problem(s), the diagnosticprocedure(s) and/or the possible management options.For the purposes of these definitions, the following organ systems are recognized: eyes, ears, nose,mouth and throat; cardiovascular; respiratory; gastrointestinal; genitourinary; musculoskeletal; skin,neurologic; psychiatric; hematologic/lymphatic/immunologic.Four types of optometric decision making are recognized: straightforward; low complexity; moderatecomplexity; and high complexity. To qualify for a given type of decision-making, two of the threeelements in the table following must be met or exceeded:Number of diagnosesor management optionsminimallimitedmultipleextensiveAmount and/or complexityof data to be reviewedminimal or nonelimitedmoderateextensiveRisk of complicationsand/or morbidity or mortalityminimallowmoderatehighType of decisionmakingstraightforwardlow complexitymoderate complexityhigh complexityCo-morbidities/underlying disease, in and of themselves, are not considered in selecting a level ofE/M services unless their presence significantly increases the complexity of the optometric decisionmaking.vi.Version 2022SELECT THE APPROPRIATE LEVEL OF E/M SERVICES BASED ON THEFOLLOWING:Page 11 of 27
Vision Care Procedure Codesa. For the following categories/subcategories, ALL OF THE KEY COMPONENTS (i.e.,history, examination, and medical decision making), must meet or exceed the statedrequirements to qualify for a particular level of E/M service: office, new patient; andconsultation.b. For the following categories/subcategories, TWO OF THE THREE KEYCOMPONENTS (i.e., history, examination, and optometric decision making) mustmeet or exceed the stated requirements to qualify for a particular level of E/Mservices: office, established patient.c. In the case where counseling and or coordination of care dominates (more than50%) the optometrist/patient and/or family encounter (face-to-face time in the office),then time is considered the key or controlling factor to qualify for a particular level ofE/M services. The extent of counseling and/or coordination of care must bedocumented in the optometric record.Version 2022Page 12 of 27
Vision Care Procedure CodesSERVICES SECTIONGENERAL INFORMATION AND RULES1. Prior Approval: Payment for those listed procedures in the Fee Schedule where theprocedure code number is underlined is dependent upon obtaining the approval of theDepartment of Health prior to performance of the procedure. If such prior approval is notobtained, no reimbursement will be made.2. Complete optometric eye examination: Codes 92002-92014 are for complete optometriceye examinations minimally comprised of a case history, an internal and external eyeexamination, objective and subjective determination of refractive state, binocular coordinationtesting, gross visual field testing and tonometry for recipients age 35 and over or others whereindicated. Routine ophthalmoscopy and confrontational testing for visual field assessment arepart of a complete optometric eye examination. The fee for the comprehensive level ofcomplete optometric eye examination requires the use of a diagnostic pharmaceutical agent asan integral part of the service and includes reimbursement for the postcycloplegic encounter.EVALUATION AND MANAGEMENT CODESCounseling and/or coordination of care with other providers or agencies are provided consistent withthe nature of the problem(s) and the patient's and/or family's needs.OFFICE SERVICESThe following codes are used to report evaluation and management services provided in theoptometrist’s office.NEW PATIENT99202 Office or other outpatient visit for the evaluation and management of a new patient, whichrequires a medically appropriate history and /or examination and straightforward medicaldecision making. When using time for code selection, 15-29 minutes of total time is spent onthe date of the encounter.99203 Office or other outpatient visit for the evaluation and management of a new patient, whichrequires a medically appropriate history and /or examination and low level of medicaldecision making. When using time for code selection, 30-44 minutes of total time is spent onthe date of the encounter.99204 Office or other outpatient visit for the evaluation and management of a new patient, whichrequires a medically appropriate history and /or examination and moderate level of medicaldecision making. When using time for code selection, 45-59 minutes of total time is spent onthe date of the encounter.Version 2022Page 13 of 27
Vision Care Procedure Codes99205 Office or other outpatient visit for the evaluation and management of a new patient, whichrequires a medically appropriate history and /or examination and high level of medicaldecision making. When using time for code selection, 60-74 minutes of total time is spent onthe date of the encounter.ESTABLISHED PATIENTThe following codes are used to report the evaluation and management services provided for followup and/or periodic reevaluation of problems or for the evaluation and management of new problem(s)in established patients.99211 Office or other outpatient visit for the evaluation and management of an established patient,that may not require the presence of a physician or other qualified health care professional.99212 Office or other outpatient visit for the evaluation and management of an established patient,which requires medically appropriate history and/ or examination and straightforward medicaldecision making. When using time for code selection, 10-19 minutes of total time is spent onthe date of the encounter.99213 Office or other outpatient visit for the evaluation and management of an established patient,which requires a medically appropriate history and/ or examination and low level of medicaldecision making. When using time for code selection, 20-29 minutes of total time is spent onthe date of the encounter.99214 Office or other outpatient visit for the evaluation and management of an established patient,which requires a medically appropriate history and/ or examination and moderate level ofmedical decision making. When using time for code selection, 30-39 minutes of total time isspent on the date of the encounter.99215 Office or other outpatient visit for the evaluation and management of an established patient,which requires a medically appropriate history and/ or examination and high level of medicaldecision making. When using time for code selection 40-54 minutes of total time is spent onthe date of the encounter.CONSULTATIONS (BY SPECIALISTS)A consultation is a type of service provided by an optometrist whose opinion or advice regardingevaluation and/or management of a specific problem is requested by another practitioner or otherappropriate source.An optometry consultant may initiate diagnostic and/or therapeutic services.The request for a consultation from the attending practitioner and the need for consultation must bedocumented in the patient’s medical record. The consultant’s opinion and any services that wereordered or performed must also be documented in the patient’s medical record and communicated tothe requesting practitioner.Version 2022Page 14 of 27
Vision Care Procedure CodesA “consultation” initiated by a patient and/or family is not reported using the consultation codes, butmay be reported using the codes for visits, as appropriate.Any specifically identifiable procedure (i.e., identified with a specific procedure code) performed on orsubsequent to the date of the initial consultation should be reported separately.On and subsequent to the date a consultant assumes responsibility for the management of a portionor all of the patient’s condition(s); the consultation codes should not be used.OFFICE CONSULTATION - New or Established PatientThe following codes are used to
Low Vision Services: Low vision examination, low vision aids and fitting of low vision aids are reimbursable to self -employed optometrists specifically certified by the New York State Optometric Association to perform low vision examinations. (Code W0021 has been deleted. To report low vision examination, use codes 92002-92014.) MMIS MODIFIERS
