016.06.07 Ark. Code R. 008
METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES -OTHER TYPES OF CARE
ATTACHMENT 4.19-B
Reimbursement is based on the lesser of the amount billed or the Title XIX (Medicaid) maximum charge allowed. The Medicaid maximum rates were established using the 2005 Medicare fee schedule. The State developed fee schedule rates are the same for both public and private providers of the service and the fee schedule and any annual/periodic adjustments to the fee schedule are published.
Reimbursement is based on the lesser of the amount billed or 68% of the dealer invoice.
Medicaid will pay a physician's fee up to the Title XIX (Medicaid) maximum for administering the injection and up to the Title XIX (Medicaid) maximum per vial of antigen. Refer to Attachment 4.19-B, Page 2, Item 5.
Rffective for claims with dates of service on or after July 1, 1992, the Title XIX maximum rates were decreased by 20%.
Visual Care
TOC not required
The following services are covered under the Arkansas Medicaid Program. "W/PA" means that a service requires prior authorization.
Procedure Code | Required Modifier | Description | Coverage | |
Under 21 Over 21 | ||||
DIAGNOSTIC AND ANCILLARY SERVICES | ||||
S0620 | - | ROUTINE OPTHALMOLOGICAL EXAMINATION INCLUDING REFRACTION; NEW PATIENT This service must include the following: case history, general health observation, external exam of the eye and adnexa, ophthalmoscopic examination, determination of refractive state, basic sensorimotor and binocularity examination. It may also include initiation of diagnostic and treatment programs or referral. | yes | yes |
S0621 | __ | ROUTINE OPTHALMOLOGICAL EXAMINATION INCLUDING REFRACTION; ESTABLISHED PATIENT This service must include the following: case history, general health observation, external exam of the eye and adnexa, ophthalmoscopic examination, determination of refractive state, basic sensorimotor and binocularity examination. It may also include initiation of diagnostic and treatment programs or referral. | yes | yes |
92340 | - | FITTING OF SPECTACLES, EXCEPT FOR APHAKIA: MONOFOCAL Fitting includes measurement of anatomical facial characteristics, the writing of laboratory specifications, and the final adjustment of the spectacles to the visual axes and anatomical topography. | yes | yes |
92370 | - | REPAIR AND REFITTING OF SPECTACLES Repair and refitting spectacles; except for aphakia | yes | yes |
99173 | UB | SCREENING TEST OF VISUAL ACUITY, QUANTITATIVE, BILATERAL This procedure must include at a minimum three components listed under procedure code S0620 or S0621. This code may not be billed in conjunction with procedure code S0620 or S0621. | yes | yes |
CONTACT LENS SERVICES | ||||
S0592 | - | COMPREHENSIVE CONTACT LENS EVALUATION This service must include the following: biomicroscopy, multiple ophthalmometry, case history, tear flow, measurement of ocular adnexa, initial tolerance evaluation, and may include other tests. This procedure does not include contact lens and should be billed in conjunction with other contact lens procedure codes. If billing this code, DO NOT bill S0620 or S0621. Contacts and glasses may be ordered using this code. | yes | yes |
S0512 | - | SUPPLYING AND FITTING OF CONTACT LENS (SOFT) Spherical, aphakic, lenticular, toric, hydrophilic (per lens) | yes W/PA | yes W/PA |
S0512 | - | SUPPLYING AND FITTING OF CONTACT LENS (GAS PERMEABLE) Spherical, aphakic,lenticular, toric, prism ballast (per lens) | yes W/PA | yes W/PA |
V2501 | UA | SUPPLYING AND FITTING OF KERATOCONUS LENS (HARD OR GAS PERMEABLE) - per lens | yes W/PA | yes W/PA |
S0512 | - | SUPPLYING AND FITTING OF MONOCULAR LENS (HARD OR GAS PERMEABLE) - per lens | yes W/PA | yes W/PA |
V2501 | U1 | SUPPLYING AND FITTING OF MONOCULAR LENS (SOFT LENS) -per lens | yes W/PA | yes W/PA |
S0512 | - | SUPPLYING AND FITTING OF CONTACT LENS (SOFT) Spherical, aphakic, lenticular, toric, hydrophilic (per lens) | yes W/PA | yes W/PA |
S0500 | - | DISPOSABLE CONTACTS (PER LENS) | yes W/PA | yes W/PA |
LOW VISION SERVICES | ||||
92002 | OPHTHALMOLOGICAL SERIVICES: Medical examination and evaluation with initiation of diagnostic and treatment program; intermediate, new patient | yes | yes | |
SUPPLEMENTAL PROCEDURES | ||||
92081 | - | VISUAL FIELD EXAMINATION Unilateral or bilateral, with interpretation and report; limited examination | yes | yes |
92082 | - | VISUAL FIELD EXAMINATION Unilateral or bilateral, with interpretation and report; intermediate examination | yes | yes |
92083 | - | VISUAL FIELD EXAMINATION Unilateral or bilateral, with interpretation and report; extended examination | yes | yes |
MISCELLANEOUS SERVICES | ||||
92100 | TONOMETRY This procedure will only be covered when medically necessary. These conditions include, but are not limited to, diabetes, hypertension and age of the patient. | yes | yes | |
92065 | __ | ORTHOPTIC AND PLEOPTIC TRAINING WITH CONTINUING MEDICAL DIRECTION AND EVALUATION | yes W/PA | no |
92060 | __ | SENSORIMOTOR EXAMINATION With multiple measurements of ocular deviation (eg, restrictive or paretic muscle with diplopia) with interpretation and report (separate procedure). | yes W/PA | no |
96111 | __ | DEVELOPMENTAL TESTING Extended (includes assessment of motor, language, social, adaptive and/or cognitive functioning by standardized developmental instruments) with interpretation and report. | yes W/PA | no |
CONTACT LENS REPLACEMENT | ||||
92326 | - | HARD LENS (PER LENS) This procedure code does not include a professional fee. | yes W/PA | no |
92326 | - | SOFT LENS (PER LENS) This procedure code does not include a professional fee. | yes W/PA | no |
92326 | - | GAS PERMEABLE (PER LENS) This procedure code does not include a professional fee. | yes W/PA | no |
92326 | - | APHAKIC LENS Post-operative cataract. | yes W/PA | yes W/PA |
V2799 | - | UNSPECIFIED PROCEDURE | yes | Yes |
EYE PROSTHESIS | ||||
V2623 | - | EYE PROSTHESIS Prosthetic eye, plastic, custom | yes W/PA | yes W/PA |
V2624 | - | POLISHING OF PROSTHESIS Polishing/resurfacing of ocular prosthesis | yes W/PA | yes W/PA |
V2625 | - | ENLARGEMENT of ocular prosthesis | yes W/PA | yes W/PA |
V2626 | - | REDUCTION of ocular prosthesis | yes W/PA | yes W/PA |
The Visual Care claim form DMS-26-V must be used by the ophthalmologists or optometrists when billing the Medicaid Program for non-prescription services. Submit the completed claim form to EDS.
If prescription services are required and are within the allowable limits outlined in section 213.200, the provider must complete the prescription form provided by the optical contractor. Visual Care providers who submit claims electronically must submit a copy of the eligibility verification for the date on which the service is being provided along with the prescription form to the optical contractor for processing. The printout will provide verification of the beneficiary's eligibility, last visual exam date and last optical prescription date. (A photocopy of the beneficiary's plastic identification card will not be accepted by the optical contractor.) The prescription form and the eligibility verification can be faxed or mailed to the optical contractor, Select Optical. View or print Select Optical's contact information.
If the copy of the eligibility on the date of service is not verified, and/or the benefit has been exhausted, the optical contractor will not fill the prescription and will return the claim to the physician.
016.06.07 Ark. Code R. 008