Vision Hardware Program Billing Guide

Vision Hardware for Clients Age 20 and Younger

Washington Apple Health (Medicaid)

Vision Hardware Program Billing Guide

(For clients age 20 and younger)

January 1, 2018

Every effort has been made to ensure this guide's accuracy. If an actual or apparent conflict between this document and an agency rule arises, the agency rules apply.

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Vision Hardware for Clients Age 20 and Younger

About this guide*

This publication takes effect January 1, 2018, and supersedes earlier billing guides to this program.

HCA is committed to providing equal access to our services. If you need an accommodation or require documents in another format, please call 1-800-562-3022. People who have hearing or speech disabilities, please call 711 for relay services.

Washington Apple Health means the public health insurance programs for eligible Washington residents. Washington Apple Health is the name used in Washington State for Medicaid, the children's health insurance program (CHIP), and state-only funded health care programs. Washington Apple Health is administered by the Washington State Health Care Authority.

What has changed?

Subject Client Eligibility

CPT Code 92072 Coverage Table

Change

Reason for Change

This section is reformatted and consolidated for clarity and hyperlinks have been updated.

Housekeeping and notification of new region moving to FIMC

Effective January 1, 2018, the agency is implementing another FIMC region, known as the North Central region, which includes Douglas, Chelan, and Grant Counties.

Removed comment "Limited to diagnosis range 371.60 to 371.62"

ICD-9 codes are no longer used. Refer to Contact lenses for current ICD code information

Removed CPT Code 92120

This code was deleted and not replaced

Removed CPT Code 92130

This code was deleted and replaced with a T code, which is not covered

*This publication is a billing instruction.

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Vision Hardware for Clients Age 20 and Younger

Subject Coverage Table

CPT Code 92132 CPT Code 92133 CPT Code 92134 Durable or flexible frames

Change Removed CPT code 92135

Reason for Change

This code was deleted and replaced by CPT codes 92133 & 92134

Removed CPT Code 92140

This code was deleted and not replaced

Added to Coverage Table

This is a covered code that has been added

Added to Coverage Table

These are covered codes that replace CPT code 92135

Added: "See Lost or broken frames or lenses for replacement frames for clients who do not have a diagnosed medical condition that contributes to broken eyeglass frames"

This is a reminder to vision providers that additional replacement frames beyond the current limit of two per client, per year, due to being broken, requires prior authorization from the agency

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Vision Hardware for Clients Age 20 and Younger

How can I get agency provider documents?

To access provider alerts, go to the agency's provider alerts webpage. To access provider documents, go to the agency's provider billing guides and fee schedules webpage.

Where can I download agency forms?

To download an agency provider form, go to HCA's Billers and providers webpage, select Forms & publications. Type the HCA form number into the Search box as shown below (Example: 13-835).

Copyright disclosure

Current Procedural Terminology (CPT) copyright 2017 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

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Vision Hardware for Clients Age 20 and Younger

Table of Contents

About this guide ........................................................................................................................ 2 What has changed? ................................................................................................................... 2 Where can I download agency forms?...................................................................................... 4

Resources Available ...................................................................................................................... 7

Definitions...................................................................................................................................... 8

About the Program ..................................................................................................................... 10

What is the scope of vision hardware program? ..................................................................... 10 What is the purpose of the program? ...................................................................................... 10 What are the general guidelines? ............................................................................................ 10 What is prior authorization (PA)?........................................................................................... 11 What provider requirements must be met? ............................................................................. 11 Who may provide vision hardware to agency clients? ........................................................... 12

Client Eligibility .......................................................................................................................... 13

Who is eligible? ...................................................................................................................... 13 Limited coverage .............................................................................................................. 13

How do I verify a client's eligibility? ..................................................................................... 13 Are clients enrolled in an agency-contracted managed care organization (MCO)

eligible?............................................................................................................................. 15 Managed care enrollment.................................................................................................. 15 Behavioral Health Organization (BHO) ........................................................................... 16 Fully Integrated Managed Care (FIMC) ........................................................................... 16 Apple Health Foster Care (AHFC) ................................................................................... 17

Coverage ...................................................................................................................................... 18

What services are covered?..................................................................................................... 18 Ocular Prosthetics ............................................................................................................. 18 Vision therapy................................................................................................................... 18 Eyeglasses (frames and lenses) ......................................................................................... 19 Eyeglasses for clients with accommodative esotropia or strabismus ............................... 19 Back-up eyeglasses ........................................................................................................... 19 Lost or broken frames or lenses ........................................................................................ 19 Durable or flexible frames ................................................................................................ 20

Coating of frames and incidental repairs ................................................................................ 20 Eyeglass lenses.................................................................................................................. 21 High index eyeglass lenses ............................................................................................... 21 Plastic photochromatic lenses ........................................................................................... 21 Polycarbonate lenses ......................................................................................................... 22 Replacement of bifocal or trifocal lenses.......................................................................... 22 Tinting............................................................................................................................... 23

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