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Routine Vision Exam Annual Limit
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Governs Alaska Medicaid coverage of routine vision examinations, specifying the one-exam-per-calendar-year limit, exceptions for children and medically justified additional exams, prior authorization requirements for adults, and required components of a covered exam. Affects providers submitting vision exam claims to Alaska Medicaid.
No material clinical or coverage changes in this revision.
Coverage criteria for routine vision examinations
Routine vision exam coverage and exceptions
Covered when the following conditions are met
Applies to procedure codes 92002-92014 and 92018-92019; determination of refractive state (92015) and visual field exams (92081-92083) are subject to the same limit.
Medical justification must be submitted with the claim.
Provider must obtain prior authorization before billing for additional exams within the same calendar year.
Required components of a covered vision exam
Covered exam must include all of the following components
If clinically indicated, perform tests of accommodation, convergence, and binocular coordination at far and near distances.
If soft lenses are prescribed, include a diagnostic evaluation to ensure proper fit and ocular health.
Problem-focused evaluation and management codes (CPT 99202–99205 and 99211–99215) are limited in use for vision-related visits. These E/M codes may only be billed when the member is being seen for a condition unrelated to the treatment of the member’s ongoing ophthalmologic conditions. Do not report these problem-focused E/M codes for services that are part of or related to routine ophthalmic care for an ongoing eye condition.
CPT and coding guidance
| 92002-92014, 92018-92019 | Vision exam procedure codes (subject to annual limit as listed) |
| 92015 | Determination of refractive state |
| 92081-92083 | Visual field examination |
| 99202-99205, 99211-99215 | Problem-focused evaluation and management procedure codes — may be used only when the member is seen for a condition unrelated to treatment of the member's ongoing ophthalmologic conditions |
Provider-required actions, documentation, and prior authorization
Prior Authorization Required
Prior authorization required for adults for additional vision exams within the same calendar year. Alaska Medicaid covers one routine vision exam per calendar year; adults needing more than one routine vision exam in the same calendar year must obtain prior authorization from the department before billing.
- Applies to routine vision exam CPT codes 92002–92014, 92018–92019, 92015 (refractive state), and visual field codes 92081–92083
Action / Alert for Providers
Providers: highlight — billing a second routine vision exam for an adult in the same calendar year without an approved prior authorization will result in denial risk. Children (≤20 years) may require medical justification submitted with the claim rather than prior authorization.
- Second routine exam for adults requires department PA
- Children through age 20 require medical justification on the claim
Required Exam Documentation
Required elements for a covered vision exam: document a complete patient history (ocular, physical, occupational, medical); evaluation of visual acuity with best correction; internal ophthalmoscopy and external check of eyes and adnexa; evaluation of ocular motility and neurologic integrity; near point subjective exam, dynamic retinoscopy, and subjective refraction. When clinically indicated include tests of accommodation, convergence, and binocular coordination. For members needing medically necessary contact lenses include slit lamp evaluation and fluorescein exam; if soft lenses are prescribed include a diagnostic evaluation.
- Document history: ocular, physical, occupational, medical
- Visual acuity with best correction determination
- Internal ophthalmoscopy and external eye/adnexa exam
- Evaluation of ocular motility and neurological integrity
- Near point subjective exam, dynamic retinoscopy, subjective refraction
- If indicated: accommodation, convergence, binocular coordination tests
- For contact lens candidates: slit lamp and fluorescein exam; diagnostic evaluation for soft lenses
Vision Exam Frequency Limit and Billing Risk
Vision exam frequency limit: only one routine vision exam is covered per calendar year. Billing more than one routine vision exam (CPT 92002–92014, 92018–92019) in the same calendar year without medical justification (for members ≤20) or an approved prior authorization (for adults) may result in claim denial. Problem-focused E/M codes (99202–99205, 99211–99215) are only appropriate when the visit is for a condition unrelated to ongoing ophthalmologic care.
- Routine vision exams subject to annual limit: 92002–92014, 92018–92019
- Refractive determination: 92015
- Visual field exams: 92081–92083
- E/M codes 99202–99205 and 99211–99215 only when unrelated to ongoing ophthalmologic treatment
Key definitions
Background and purpose
Routine vision examinations assess visual acuity, refractive status, ocular health, and binocular function and are intended to determine the need for corrective lenses and to identify ocular disease. Alaska Medicaid covers one routine vision exam per calendar year; procedure codes subject to this limit include vision exam codes (92002–92014, 92018–92019), determination of refractive state (92015), and visual field testing (92081–92083).
A covered routine exam must include a complete patient history and a clinical evaluation that documents visual acuity with best correction, internal ophthalmoscopy and external eye/adnexa assessment, ocular motility and neurological evaluation, near point subjective testing, dynamic retinoscopy, and subjective refraction. When clinically indicated, perform tests of accommodation, convergence, and binocular coordination. For members requiring medically necessary contact lenses, include slit lamp and fluorescein examination and appropriate diagnostic evaluation for soft lenses to ensure proper fit and ocular health.
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