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General and Special Services, continued

General and special ophthalmological services are not reimbursed when they are performed as part of a routine screening for eyeglasses for adults.

General and special ophthalmological services for all conditions are not reimbursed when they are performed in a nursing facility, an ICF/DD, a recipient’s home, or a custodial care facility.

Note: See the Florida Medicaid Optometric Services and the Visual Services Coverage and Limitations Handbooks for additional information. The

handbooks are available on the Medicaid fiscal agent’s Web site at

www.mymedicaid-florida.com. Select Public Information for Providers, then Provider Support, and then Provider Handbooks.

Surgical Care Only If performing surgical care only, the provider must bill using modifier 54 appended to the appropriate surgery procedure code.

Blepharoplasty Blepharoplasty is surgical repair of drooping eyelids by removing excess skin, muscle and fat. This surgical procedure is considered cosmetic, unless the drooping or sagging of the eyelid(s) interferes with the recipient’s vision.

Blepharoplasty procedures require prior authorization from Medicaid.

Requests for prior authorization of blepharoplasty procedures must be submitted with all of the following documents and information:

• A completed Florida Medicaid Authorization Request Form, (PA01), signed and dated by an enrolled Florida physician with:

− Appropriate code modifier and quantity when requesting a bilateral procedure;

• History and physical;

• Automated perimeter test results;

• Frontal photographs (including the chin) with:

− Head perpendicular to the camera (not tilted);

− Showing the light reflex on the cornea.

Note: See the Florida Medicaid Provider Reimbursement Handbook, CMS-1500, for additional information regarding prior authorizations and instructions for completing the Florida Medicaid Authorization Request Form, PA 01. The handbooks are available on the fiscal agent’s Web site at www.medicaid-florida.com. Select Public Information for Providers, Provider Support and then select Provider Handbooks. Forms are also available on the fiscal agent’s Web site. Select Public Information for Providers, then Provider Support and then Forms.

Ophthalmological Services

Re-Examinations Medicaid does not reimburse for vision re-examinations that include CPT evaluation and management codes and general ophthalmological visits, performed exclusively for checking an eyeglasses prescription dispensed by the same provider within the previous 30 days.

Intravitreal Implant An intravitreal implant is reimbursed using HCPCS procedure code J7310. A copy of the invoice must be maintained in the recipient’s medical record.

Reimbursement is limited to four implants per year, per recipient.

Computerized Corneal Topography

Medicaid reimburses computerized corneal topography up to a maximum of four times per year, per recipient.

Refractions Refractions are reimbursable to physicians with an ophthalmology specialty.

Medicaid will reimburse two medically necessary refractions in 365 days, per recipient. The date of the first refraction begins the 365 day period.

For dually-eligible Medicare and Medicaid recipients, providers must enter keyed claim type 63 in item 19 on a paper CMS-1500 claim form when submitting claims for refractions and visual examinations using a refractive error diagnosis (367.0-367.9).

Providers with ophthalmology specialty should also enroll in the Medicaid Optometric and Visual Services Programs to bill for services related to the provision, fitting, dispensing and adjusting of corrective lenses. See Visual Services Enrollment in this section for more information.

Medicaid does not reimburse refractions performed in a nursing facility, an ICF/DD, a recipient’s home, or a custodial care facility.

Note: See the Florida Medicaid Provider Reimbursement Handbook, CMS-1500 for information.

Note: See the Florida Medicaid Optometric Services Coverage and

Limitations Handbook for additional information. The handbook is available on the Medicaid fiscal agent’s Web site at www.mymedicaid-florida.com. Select Public Information for Providers, then Provider Support, and then Provider Handbooks.

Ophthalmological Services

Lacrimal Punctum Plugs

Medicaid reimburses for medically-necessary lacrimal punctum plugs.

Service Requirements

Medicaid reimburses for lacrimal punctum plugs for recipients who meet the following criteria:

• Are diagnosed with either:

− 375.15 - Tear film insufficiency, unspecified; dry eye syndrome; or

− 370.33 - Keratoconjunctivitis sicca, not specified as Sjögren’s;

• Have complaints that are normally associated with dry eye syndrome;

• Have a positive Schirmer's test or some other measurement of lacrimal gland deficiency or evidence of corneal decomposition by slit lamp exam;

• Have undergone two to four weeks of conventional treatment using eye drops, gels, or ointments; and

• Show no evidence of any improvements after conventional treatments.

Required Documentation

The provider must maintain all of the following documentation for each claim in the recipient’s medical record:

• Recipient’s diagnosis code supporting the medical necessity for the procedure;

• Results of Schirmer test or equivalent tear break-up time, tear assay, zone-quick and slit lamp exam;

• Operative report that contains:

− Patient’s signature consenting to the procedure;

− Which puncta were involved;

− What plugs were used, described by type (collagen, silicone acrylic), brand and size;

− Whether the patient received topical anesthesia;

− What were pre-op and post-op diagnoses; and

− Discharge instructions.

If the above listed documentation is not in the recipient’s medical record, the claim is subject to recoupment.

Ophthalmological Services

Contraindications Use of lacrimal punctum plugs is contraindicated in recipients with any of the following:

• Signs and symptoms of an infection;

• Inflammation of eyelids;

• Dacryocystitis; or

• Allergies to bovine collagen or silicone.

Reimbursement Limitations

Temporary lacrimal punctum plugs are limited to 12 per year (maximum of four plugs every four months), for procedure code 68761, for treatment of dry eye syndrome when a more permanent conservative treatment will cause discomfort to the recipient. Documentation must be maintained in the recipient’s medical record.

Procedure code 68761, (closure of lacrimal punctum by plug, each), includes reimbursement for plugs; therefore, the plug may not be billed separately.

Service Exclusions A routine eye exam in the absence of a reported vision problem, an illness, disease, or injury is not reimbursable.

MediPass Authorization Exemption

Ophthalmologists are not required to obtain MediPass authorization, except for prosthetic eye services.