Provider Alert! CPT Codes for Vision Testing Reminder

Date: October 12, 2022

Attention: All Providers

Providers should monitor the Texas Children’s Health Plan (TCHP) Provider Portal regularly for alerts and updates associated to the COVID-19 event. TCHP reserves the right to update and/or change this information without prior notice due to the evolving nature of the COVID-19 event.

Call to action: The purpose of this communication is to remind providers about Texas Children’s Health Plan’s (TCHP) Current Procedural Terminology (CPT) codes for vision testing and medically necessary eye examinations. Vision testing and examination and treatment of eye conditions are benefits of Texas Medicaid and may be reimbursed to ophthalmologist or optometrist providers.

How this impacts providers:

Medically necessary eye examinations

An eye examination with or without refraction may be reimbursed for medical evaluations and examinations using the following procedure codes:

• Procedure codes 92002, 92004, 92012, 92014, and 92015 will not be reimbursed for routine exams. Documentation in the member’s medical record must support the medical necessity of the service performed.
• Procedure codes 92002, 92004, 92012, and 92014 may be reimbursed when it is medically necessary to ophthalmologist or optometrist providers for medically necessary eye examinations without refraction.

• Procedure codes 92002, 92004, 92012, and 92014 are limited to one service per day by any provider.

Routine eye examinations

An eye examination with refraction testing may be reimbursed using the following procedure codes:

• A refractive state (procedure code 92015) will be denied as part of another service if it is billed with the same date of service by any provider as procedure code S0620 or S0621.

Next steps for providers: Providers are encouraged to share this communication with their staff.

If you have any questions, please email Provider Network Management at: providerrelations@texaschildrens.org.

For access to all provider alerts, log into:
www.thecheckup.org or www.texaschildrenshealthplan.org/for-providers