Notification



Notification Issue Date:



Claim Payment Policy


Title:Instrument-Based Vision Screening

Policy #:07.13.12d


Application of Claim Payment Policy is determined by benefits and contracts. Benefits may vary based on product line, group or contract. Medical necessity determination applies only if the benefit exists and no contract exclusions are applicable. Individual member benefits must be verified.

In products where members are able to self-refer to providers for care and services, members are advised to use participating providers in order to receive the highest level of benefits.When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

For more information on how Claim Payment Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract.

The Company considers instrument-based vision screening to be an integral part of the Evaluation and Management Service and is, therefore, not eligible for reimbursement whether billed alone or in conjunction with other services. Participating providers may not bill members for this service.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.


Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, instrument-based vision screening is covered under the medical benefits of the Company's products.

Description

Instrument-based vision screening is an alternative vision screening method to detect the risk factors for amblyopia, which include strabismus (a misalignment of the eyes in any direction), media opacities (eg, cataracts), and refractive errors (eg, myopia, hyperopia, astigmatism, presbyopia). It consists of photoscreening and autorefraction.

Photoscreening is a technique that uses the principle of photorefraction, in which the refractive state of the eye is assessed via the pattern of light that is reflected through the pupil. In photoscreening, optical images of the eye’s red reflex estimate refractive error, media opacity, ocular alignment, and other factors, such as ocular adnexal deformities (eg, ptosis), all of which put a child at risk for developing amblyopia. Performed in a darkened room, photoscreening requires little cooperation from the individual, other than fixating on a target for the duration of the screening process. Images of the pupillary reflexes (autonomic reflex constrictions caused by light) and red reflex (a circular red light reflected from the retina of the eye) are obtained. The photographs can then be analyzed by the evaluator or sent to a central laboratory for analysis by an ophthalmologist or specially trained personnel. Test results are typically graded as pass or fail, or equivocal, in which case the procedure must be repeated.

Autorefraction is a technique that uses several types of automated methods (eg, optically automated skiascopy or wavefront technology), which evaluate the refractive error of each eye. Data from autorefraction yield numeric results that are analyzed by the evaluator or by the instrument itself to determine if a child passes or fails the screening.
References

Provider Manuals


Visual System Assessment in Infants, Children, and Young Adults, by Pediatricians. American Academy Of Pediatrics. January 1, 2016. https://pediatrics.aappublications.org/content/pediatrics/137/1/e20153596.full.pdf Accessed February 25, 2020



Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

99174, 99177


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD-10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD-10 Diagnosis Code Number(s)

N/A


HCPCS Level II Code Number(s)

N/A


Revenue Code Number(s)

N/A


Coding and Billing Requirements


Cross References


Policy History

07.13.12d
03/25/2020This policy has been reviewed and reissued to communicate the Company’s continuing position on Instrument-Based Vision Screening.
Version Effective Date: 01/01/2016
Version Issued Date: 12/31/2015
Version Reissued Date: 03/25/2020



2017 AmeriHealth.