5101:3-6-07 Covered vision services.

(A) General ophthalmological services.

(1) A "comprehensive ophthalmological service" is a general evaluation of the complete visual system The service includes history, general medical observation, external and ophthalmoscopic examination, gross visual fields and basic sensorimotor examination. It can includes: biomicroscopy, examination with cycloplegia or mydriasis, tonometry and determination of refractive state. Comprehensive ophthalmological services always include initiation of diagnostic and treatment programs (e.g. prescription of lenses). In order to be reimbursed, providers must use the following procedure codes when rendering comprehensive ophthalmological services:

For dates of service beginning on and after April 1, 2004, to be reimbursed for comprehensive ophthalmologic services, bill the following codes:

(a) Code 92004 for a new consumer or code 92014 for an established consumer.

(b) If the individual receiving special ophthalmologic services is either twenty years of age or under or sixty years of age or older, codes 92004 and 92014 must be billed in conjunction with modifier UB, i.e., 92004UB.

(c) The UB modifier allows for a comprehensive ophthalmologic service once per year.

(2) An "intermediate ophthalmological service" is an evaluation of a new or existing condition complicated with a new diagnostic or management problem not necessarily relating to the primary diagnosis. An intermediate ophthalmological service includes history, general medical observation, external ocular and adnexal examination and other diagnostic procedures. The following procedure codes must be used in order to be reimbursed for rendering intermediate ophthalmological services.

(a) 92002 - New patient intermediate service; or

(b) 92012 - Established patient intermediate service.

(B) Other vision care services including covered ophthalmological/optometric diagnostic and treatment services:

(1) For the detection and/or treatment of ocular abnormalities that may be evidence of disease, pathology or injury, vision care providers may bill for services using the appropriate evaluation and management service level code (99XXX series) in accordance with the physicians' "Current Procedural Terminology (CPT)," code definitions and instructions as referenced in rule5101:3-1-60 of the Administrative Code. These services may be subject to review by the department to determine whether they are necessary to detect or treat, within the scope of the provider's license, ocular abnormalities that may be evidence of disease, pathology, or injury. These evaluation and management services codes may not be billed with the general ophthalmological service codes listed in paragraphs (A)(1) and (A)(2) of this rule.

(2) A "refractive service" is the medicaid-covered component of a comprehensive eye exam provided to a medicaid and medicare-covered consumer in conjunction with other medicare covered eye exam procedures. It is only reimbursed as a separate and distinct service by medicaid when medicare payment for an eye exam does not include payment for the refraction services component of the exam. Use code 92015 to bill for the refraction component of a medicare-covered exam. Code 92015 cannot be billed in conjunction with the general ophthalmological service codes listed in paragraphs (A)(1) and (A)(2) of this rule.

(3) "Special ophthalmological/optometric services", non-routine ophthalmoscopy and other specialized ophthalmological services are medicaid-covered and are reimbursable by billing the appropriate physicians' "Current Procedural Terminology (CPT)" code as referenced in rule5101:3-1-60 of the Administrative Code. These services are subject to review by the department to determine whether the service is necessary to detect or treat ocular abnormalities that may be evidence of disease, pathology

(4) Certain vision procedures listed under the "Special Ophthalmological Services," the "Ophthalmoscopy," and the "Other Specialized Services" section of the CPT have been identified as diagnostic and therapeutic procedures which are composed of professional and technical components. These services are specifically identified, must be billed, and shall be reimbursed in accordance with rule5101:3-4-11 of the Administrative Code.

Effective: 01/01/2006
R.C. 119.032 review dates: 09/29/2005 and 01/01/2011
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02
Prior Effective Dates: 5/9/86, 8/1/86, 8/22/88 (Emer), 11/18/88, 7/1/93, 7/1/94, 7/1/02, 4/1/04