Vision Services

Field Representatives:

Amy Buxton and Kelly Miller 2/2/13

Wyoming Medicaid

Who Can Provide Services

A licensed Ophthalmologist • 207W00000X A licensed Optometrist

• 152W00000X Optician

• 156FX1800X

February 4, 2013 2

Covered Services – 21 and over

Eye Examination • Codes: 92002, 92004, 92012, and 92014 Treatment of eye disease or eye injury only Based on appropriate ICD-9 diagnosis codes

• Contacts and glasses are not covered Payment of deductible and/or coinsurance due on

Medicare crossover claims for post-surgical contact lenses and/or eyeglasses

February 4, 2013 3

Covered Services – 20 and under

Eye examination • Codes: 92002, 92004, 92012, and 92014 • Ophthalmologic procedures codes: 92015-92140 Eyeglasses

• Lenses Single vision, bifocal, or trifocal lenses are covered When deemed medically necessary by an ophthalmologist or optometrist,

with physician records also reflecting medical necessity Codes: V2700-V2799 with prior authorization (PA) Codes: V2715 and V2784 no PA required Polycarbonate lenses (V2784), includes scratch resistant coating,

must be billed as an add-on to a standard C-39 lens

February 4, 2013 4

Covered Services – 20 and under

High index aspheric lenses • Codes: V2410, V2430, V2499 Covered when medically necessary and meet the

guidelines Can be used when the power in the highest meridian is –

(minus) 6.00 diopters or more Can be used for plus prescriptions when the power in the

highest meridian is + (plus) 4.00 diopters or more Lenses should be ordered in pairs – when one side is

aspheric or high index, then the matching lens should also be aspheric or high index even if it doesn’t meet the threshold.

February 4, 2013 5

Covered Services – 20 and under

Frames • Codes: V2020-V2499 • One set of frames covered per 365 days Replacement of lenses within 365 days must be due to

medical necessity Must use existing frames

• Repair or replace frames if warranty available If no warranty, it will be the client’s responsibility

• Medicaid allows up to $76 for standard frames

February 4, 2013 6

Covered Services – 20 and under

• No balance billing If the client wants frames that cost more than $76, two

options exist: Accept $76 as payment in full from Medicaid for the

frames – client pays nothing Client pays the full price and the frames are NOT billed

to Medicaid – agreement in writing must be placed in the client’s file

• Client may contract to pay for optional add on services (tints, coatings, etc.) Obtain agreement specific to items client is agreeing to

pay for

February 4, 2013 7

Covered Services – 20 and under

Contact lenses • Codes: V2500-V2599 • Covered when medically necessary for the

correction of pathological conditions when useful vision cannot be obtained with regular lenses

• Effective March 1st, 2013, prior authorization is required. Documentation provided must show medical necessity and state why the client’s vision cannot be corrected with eyeglasses.

February 4, 2013 8

Covered Services – Vision Therapy

Who’s Covered • Clients under the age of 21 • Clients 21 and over on the Acquired Brain Injury

Waiver (ABIW) Plan Procedure Codes

• Code: 92065 – vision therapy No prior authorization required

• Code: 99070 – therapy training aids Submit the claim with invoice and statement of

medical necessity

February 4, 2013 9

Covered Services – Vision Therapy

Diagnosis Codes • Services are covered for specific diagnosis codes

(see charts following limitations) • If a diagnosis code is not covered, an appeal may

be submitted Appeals must be a request in writing that the diagnosis

code be covered Appeals must be submitted to Provider Relations and

approved by the Division of Healthcare Financing to be processed for payment

February 4, 2013 10

Covered Services – Vision Therapy

Limitations • Clients are allowed only 32 sessions per 365 days Medical necessity is required for services beyond the

allowed 32 sessions

February 4, 2013 11

Covered Services – Vision Therapy Vision Therapy Diagnosis Codes

Amblyopia 368.01 Strabismic amblyopia

368.02 Deprivation amblyopia

368.03 Refractive amblyopia

Strabismum (Concomitant) 378.01 Monocular esotropia

378.05 Alternating esotropia

378.11 Monocular exotropia

378.15 Alternating exotropia

378.12 Intermittent esotropia, monocular

378.22 Intermittent esotropia, alternating

378.23 Intermittent exotropia, monocular

378.24 Intermittent exotropia, alternating

378.35 Accommodative component in esotropia

February 4, 2013 12

Covered Services – Vision Therapy

February 4, 2013 13

Vision Therapy Coding

Non-strabismic disorder of binocular eye movements

378.83 Convergence insufficiency

378.84 Convergence excess

378.85 Anomalies of divergence

Ocular Motor Dysfunction

379.57 Deficiencies of saccadic eye movements

379.58 Deficiencies of smooth pursuit movements

Heterophoria

378.41 Esophoria

378.42 Exophoria

General Binocular Vision Disorder

368.30 General Binocular Vision Disorder

Accommodative Disorder

367.5 Accommodative Disorder

Nystagmus

379.51 Nystagmus

Covered Services – Vision Therapy Acquired Brain Injury Program

438.7 Disturbances of vision 907.0 Late effect of injury intracranial injury

without mention of skull fracture 997.0 Central Nervous System complications, not

classified elsewhere V57.4 Care involving orthoptic training

February 4, 2013 14

Common Denial Reasons and Solutions Client not eligible for date of service or the service

is not covered under the client’s plan • To avoid time lost in billing unnecessary claims to

Wyoming Medicaid, it is important to verify eligibility of each client, keeping in mind that eligibility is authorized on a monthly basis and can change from month to month. Not all Medicaid plans cover vision services; some

are limited to prescriptions only, payment of Medicare premiums, or coverage for limited diagnoses or conditions.

Eligibility can be verified at no cost via the IVR (800-251-1268), using either the client’s Medicaid ID or their SSN.

February 4, 2013 15

Common Denial Reasons and Solutions Procedure Code/Age Conflict As certain services are only covered for certain age individuals, it is

important to verify the covered ages for the procedure codes before performing the service and billing, as well as the age of the client.

The Wyoming Medicaid website contains a fee schedule search engine which will allow the provider to enter any procedure code to view information related to: Allowed amount Prior authorization requirement Age limitations Allowed taxonomies Maximum units Allowed/disallowed modifiers Medicare coverage (required to be billed to Medicare if client is covered

under Medicare)

February 4, 2013 16

Common Denial Reasons and Solutions

Client is covered by Medicare or another insurance – commonly referred to as TPL (Third Party Liability) Medicaid is the payer of last resort. This means that providers must

bill their claim to other payers first, obtain any payment or denial, and include this information when billing claims to Medicaid.

If providers find that they are having difficulty obtaining response from any insurance (not including Medicare), they may include a letter documenting at least 2 attempts over a minimum of 90 days and Medicaid will process as primary and obtain payment from the other insurance.

If providers are non-participatory with any insurance (not including Medicare), they may include a letter documenting this in place of the other insurance’s EOB.

Note: Medicare must be billed primary in all cases, and providers must include the Medicare EOMB if the procedure code is marked as Medicare: Y on the fee schedule

February 4, 2013 17

Chapter 7 of the Provider Manual

Chapter 7 : Third Party Liability • Definition of a Third Party Payer • When Clients have Third Party Liability (TPL) • Identifying Other Sources of Coverage • Exceptions to Billing Third Party Payers First • Billing Third Party Payers • Previous Attempts to Bill Services • Coordination of Benefits • Questions about TPL • Third Party Resources Information Sheet

February 4, 2013 18

Common Denial Reasons and Solutions

Procedure code requires PA • Certain services require PA for medical necessity

prior to the service being rendered. • Verify if the code being billed requires PA

View Fee Schedule on the website Contact Provider Relations

• Fill out the PA Form Available on the website Chapter 6, Section 6.12 of the CMS-1500 Manual

February 4, 2013 19

References The information reviewed in this presentation can be found in the CMS-

1500 Manual Wyoming Medicaid Website – http://wyequalitycare.acs-inc.com

• Provider Manuals Click on Provider / Provider Manuals and Bulletins / Vision / CMS-1500 Provider Manual

• Fee schedule Click on Provider / Fee Schedule / Accept / Try our procedure code search page

• IVR Navigation tips Helps direct providers on which options to chose to get to the appropriate department Click on Provider / Contact Us / Click here for helpful Provider IVR Navigation Tips

• Remittance Advice Retrieval From the Secure Provider Web Portal

• Medicaid and State Healthcare Benefit Plan document Click on Provider / Provider Manuals and Bulletins / Additional Links

February 4, 2013 20

References IVR – 1-800-251-1268 24 hours a day / 7 days per week Touchtone phone is required Payment Inquiries, Medicaid client number and information, Lock-in status,

Medicare Buy-in data, Service limitations To Verify Eligibility

Provider can use the client ID or client SSN Gives provider the name of the plan the client is on Option to listen to detailed information regarding the plan

Medical Policy – 800-251-1268 (Option 1,1,4,3) 9-5 MST Monday - Friday Questions regarding how to fill out the prior authorization form, questions

regarding status of PA, etc. Cap limit waiver requests

February 4, 2013 21

References Provider Relations – 800-251-1268 (Option 1,5,0) 9-5 MST Monday - Friday Bulletin / Manual inquiries Cap limits Claim inquiries Claim submission problems Client eligibility Questions on completing forms Payment inquiries Timely filing inquiries Troubleshooting prior authorization problems Verifying validity of procedure codes Claim void / adjustment inquiries

February 4, 2013 22

Questions?

February 4, 2013 23