CurrentAlaska MedicaidPolicy N/A

Routine Vision Exam Annual Limit

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.

Policy Summary

PayerAlaska Medicaid

PolicyRoutine Vision Exam Annual Limit

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization for adults seeking additional vision exams within the same calendar year.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1/yrcovered routine vision exam frequency

children ≤20additional exams allowed

adultsprior auth required

92002-92019codes subject to limit

Coverage criteria for routine vision examinations

Routine vision exam coverage and exceptions

Covered when the following conditions are met

Annual routine exam: One routine vision exam is covered per calendar year.1 per calendar year

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.

Additional exams for children through 20 years of age are covered when medical justification is submitted with the claim.age ≤ 20 with documentation

Medical justification must be submitted with the claim.

Additional exams for adults are covered only with prior authorization by the department.prior authorization required

Policy Summary

PayerAlaska Medicaid

PolicyRoutine Vision Exam Annual Limit

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization for adults seeking additional vision exams within the same calendar year.

SourceLink

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Required components of a covered vision exam

Covered exam must include all of the following components

Required exam components: Complete patient history (including ocular, physical, occupational, and medical); evaluation of visual acuity with best correction determination; internal ophthalmoscopy and external check of eyes and adnexa; evaluation of ocular motility and neurological integrity; near point subjective examination, dynamic retinoscopy, and subjective refraction.procedural completeness

If clinically indicated, perform tests of accommodation, convergence, and binocular coordination at far and near distances.

Contact lens patients: For members requiring medically necessary contact lenses, the exam must include a slit lamp evaluation and a fluorescein examination.contact lens specific

If soft lenses are prescribed, include a diagnostic evaluation to ensure proper fit and ocular health.

Provider-required actions, documentation, and prior authorization

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

Note

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

Documentation Required

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

Denial Risk

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

inv-13: Routine vision exam

DefinitionA routine vision exam is a covered eye examination; Alaska Medicaid covers one vision exam per calendar year (procedure codes 92002–92014 and 92018–92019).

ScopeIncludes evaluation of visual acuity, refractive status, ocular health, and binocular function when services exceed those bundled into the listed vision exam procedure codes.

Procedure codes subject to limitVision exam codes 92002–92014 and 92018–92019 are subject to the annual limit; related codes subject to the same limit include determination of refractive state (92015) and visual field exam (92081–92083).

Frequency limitOne routine vision exam per calendar year is covered; additional exams for children ≤20 require medical justification submitted with the claim; adults require prior authorization.

Use of E/M codesProblem-focused E/M codes (99202–99205, 99211–99215) may be used only when the member is seen for a condition unrelated to treatment of the member's ongoing ophthalmologic conditions.

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.

OpenPayer

Routine Vision Exam Annual Limit

Coverage criteria for routine vision examinations

CPT and coding guidance

Provider-required actions, documentation, and prior authorization

Key definitions

Background and purpose