MA PPO

Instrument-Based Vision Screening
MA07.048a


Policy

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

There is no Medicare coverage determination addressing this service; therefore, the Company policy is applicable.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, instrument-based vision screening is covered under the medical benefits of the Company's Medicare Advantage 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 (e.g., cataracts), and refractive errors (e.g., 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 to estimate refractive error, media opacity, ocular alignment, and other factors, such as ocular adnexal deformities (e.g., 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, fail, or if the procedure must be repeated if results are equivocal.

Autorefraction is a technique that uses several types of automated methods (e.g., 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

Evidence of Coverage

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

CPT Procedure Code Number(s)

99174, 99177


ICD - 10 Procedure Code Number(s)
N/A

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



Policy History

1/1/2026
1/5/2016
3/25/2020
MA07.048
Claim Payment Policy Bulletin
Medicare Advantage
Yes