CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Vision Care Documentation and Billing Guidelines

Guidelines governing billing, coding, documentation, and reimbursement for vision care services and hardware for Neighborhood Health Plan of Rhode Island providers; applies to all places of service and claim types for affected members.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyVision Care Documentation and Billing Guidelines

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJul 1, 2011

Next Review DateN/A

Key ActionPatient records are required for all frames submitted after the second pair rendered to the same patient within a 12-month period.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2pairs policy triggers patient record requirement after the second pair in 12 months

92370CPT code cited for reporting repairs or replacement parts

CMS-1500claim forms to which guideline applies

Allplaces of service applicability

Vision Care Coverage and Billing Criteria

Vision care billing and documentation criteria

Covered when criteria below are met:

Services should be billed under the rendering provider name and NPI number.

When billing for hardware, use either the ordering date or the pick up date as the date of service (choose one method and bill consistently).

Eyeglasses are not billable to NHPRI when repair or replacement is required due to defects in materials or workmanship; such items should be returned to the manufacturer.

Reimbursement is available for repair or replacement of eyeglass parts when damage is due to causes other than defective materials or workmanship; report repairs or replacement parts with CPT code 92370.

Patient records are required for all frames submitted after the second pair rendered to the same patient within a twelve month period.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyVision Care Documentation and Billing Guidelines

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJul 1, 2011

Next Review DateN/A

Key ActionPatient records are required for all frames submitted after the second pair rendered to the same patient within a 12-month period.

SourceLink

On This Page

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Documentation, Recoupment, and Billing Actions

Documentation Required

Documentation and Recoupment

Providers must maintain complete documentation for vision care services and hardware. Patient records should support billed diagnoses, include the pickup date and signature of the person picking up eyeglasses, and document circumstances for replacement of lost or destroyed eyeglasses. Services should be billed under the rendering provider name and NPI. When billing for hardware, use either the ordering date or the pickup date (not both) and be consistent in method. All services must be billed according to applicable ICD-9/ICD-10, CPT, and HCPCS guidelines and the diagnosis billed must support the charges submitted.

Bill services under the rendering provider name and NPI
Use either ordering date or pickup date for hardware billing (not both) and be consistent
Diagnosis billed must support the charges and reflect the patient’s condition
Bill according to ICD-9/ICD-10, CPT, and HCPCS guidelines
Pickup date and signature of person receiving eyeglasses must be in patient record
Patient records required for all frames submitted after the second pair to same patient in 12 months
Eyeglasses not billable to NHPRI for repairs/replacement due to defects in materials or workmanship — return to manufacturer
Reimbursement allowed for repair/replacement when damage is not due to defective materials or workmanship (report repair/replacement with CPT 92370)
Reimbursement allowed for medically necessary replacement of lost/destroyed eyeglasses; document circumstances in member record
NHPRI reserves the right to recoup funds for any service not documented in the patient record
Guideline applies to CMS-1500 and UB-92 claim submissions and all places of service

Definitions and Exclusions

Date of service (hardware)

Accepted DOS methodsDate of service for hardware billing must be either the ordering date or the pick up date; choose one method and bill consistently (do not use both).

Billing consistencyApply the chosen DOS method consistently across claims for hardware to ensure compliance.

Applicable claim formsGuideline applies to both CMS-1500 and UB-92 claim submissions.

Defective materials/workmanship exclusion

Exclusion statementEyeglasses should not be billed to NHPRI when repair or replacement is required due to defects in quality of materials or workmanship; such items should be returned to the manufacturer.

When reimbursement is allowedReimbursement is available for repair or replacement when damage is due to causes other than defective materials or workmanship; report with CPT code 92370.

Replacement parts requirementReplacement parts should duplicate the original prescription and frame style.

Replacement for lost/destroyed eyeglasses

Reimbursement conditionReplacement of lost or destroyed eyeglasses is reimbursable when medically necessary.

Duplication requirementThe replacement complete pair should duplicate the original prescription and frames.

Documentation requirementAn explanation of the circumstances surrounding replacement of the complete pair of eyeglasses should be documented in the member's record.

OpenPayer

Vision Care Documentation and Billing Guidelines

Vision Care Coverage and Billing Criteria

Codes, Reporting, and Documentation Thresholds

Documentation, Recoupment, and Billing Actions

Definitions and Exclusions