Vision Therapy
Authorization
Evaluations for qualified conditions are to be submitted directly through eClaim with the appropriate diagnosis codes indicated.
Sessions for a patient who meets the benefit criteria and is eligible for Vision Therapy are authorized when you obtain a case number. To get one, complete a Vision Therapy Verification Form. Fax it to 916.851.4733, or mail the form to: VSP, PO Box 997100, Sacramento, CA 95899. You can find this form under Benefit Administration in the Forms section of the Administration menu on VSPOnline at eyefinity.com or in the Tools and Forms section of this manual.
Coverage
Evaluations
We’ll pay a maximum of $85 for one approved sensorimotor exam per service year. You may not balance bill the patient for any amount over the approved amount. The $85 maximum per year for the exam is not included in the $750 yearly vision therapy allowance described below.
Sessions
The number of vision therapy sessions is dependent upon pre-established benefit criteria, indicated on the Benefit Authorization Notice along with the case number. This information is available after we receive your completed Vision Therapy Verification Form.
For orthoptic and/or pleoptic training (therapy sessions) the maximum allowed is $750 annually. VSP pays 75% of allowed amount, patient's responsibility is 25%. Additional sessions beyond those covered by us are a private transaction between you and your patient.
- Max allowable per session up to $50, VSP pays 75%, patient is responsible for 25%.
Note:
VSP pays 100% of the allowable amount for vision therapy sessions provided to patients with an Eyes of Hope gift certificate.
Patients with Eyes of Hope Gift Certificates: In addition to the sensorimotor exam, we'll pay 100% of the allowed amount for vision therapy sessions up to $750 for each person per service year. The patient does not have to pay the 25% patient fee.
Medicaid: VSP pays 100% of the billed amount up to fee schedule. No copay or charge to the member for covered services. Based on state guidelines, refer to Medicaid Fee Schedule.
Submitting Claims/Billing
For Vision Therapy sessions, include the authorization number from the Benefit Authorization notice in Box 23 located on the Diagnosis and Services screen on eClaim. Also include one of the CPT procedure codes and an appropriate diagnosis code from the tables below:
Note:
Vision therapy claims must be submitted on a separate claim from routine vision. CPT and HCPCS codes are not selectable from the drop-down box and must be manually entered.
Sensorimotor Exam
|
92060 |
Sensorimotor examination with multiple measurements of ocular deviation, with interpretation and report. |
Vision therapy evaluation (to report use CPT code 92060) is allowable for the following diagnoses
|
CD-10-CM |
Description |
|
H50.06 |
Alternating esotropia with A pattern |
|
H50.07 |
Alternating esotropia with V pattern |
|
H50.111 |
Monocular exotropia, right eye |
|
H50.112 |
Monocular exotropia, left eye |
|
H50.141 |
Monocular exotropia with other noncomitancies, right eye |
|
H50.142 |
Monocular exotropia with other noncomitancies, left eye |
|
H50.15 |
Alternating exotropia |
|
H50.18 |
Alternating exotropia with other noncomitancies |
|
H50.30 |
Unspecified intermittent heterotropia |
|
H50.311 |
Intermittent monocular esotropia, right eye |
|
H50.312 |
Intermittent monocular esotropia, left eye |
|
H50.32 |
Intermittent alternating esotropia |
|
H50.331 |
Intermittent monocular exotropia, right eye |
|
H50.332 |
Intermittent monocular exotropia, left eye |
|
H50.34 |
Intermittent alternating exotropia |
|
H50.51 |
Esophoria |
|
H50.52 |
Exophoria |
|
H51.11 |
Convergence insufficiency |
|
H51.12 |
Convergence excess |
|
H51.8 |
Other specified disorders of binocular movement |
|
H53.32 |
Fusion with defective stereopsis |
|
H55.81 |
Saccadic eye movements |
|
H55.82 |
Deficient smooth pursuit eye movements |
|
H55.89 |
Other irregular eye movements |
Vision Therapy Sessions
|
92065 |
Orthoptic training |
Vision therapy sessions (to report use CPT code 92065) are allowable for the following diagnoses:
|
ICD-10-CM Code |
Description |
|
H50.041 |
Monocular esotropia with other noncomitancies, right eye |
|
H50.042 |
Monocular esotropia with other noncomitancies, left eye |
|
H50.05 |
Alternating esotropia |
|
H50.06 |
Alternating esotropia with A pattern |
|
H50.07 |
Alternating esotropia with V pattern |
|
H50.10 |
Unspecified exotropia |
|
H50.111 |
Monocular exotropia, right eye |
|
H50.112 |
Monocular exotropia, left eye |
|
H50.141 |
Monocular exotropia with other noncomitancies, right eye |
|
H50.142 |
Monocular exotropia with other noncomitancies, left eye |
|
H50.15 |
Alternating exotropia |
|
H50.18 |
Alternating exotropia with other noncomitancies |
|
H50.21 |
Vertical strabismus, right eye |
|
H50.22 |
Vertical strabismus, left eye |
|
H50.30 |
Unspecified intermittent heterotropia |
|
H50.311 |
Intermittent monocular esotropia, right eye |
|
H50.312 |
Intermittent monocular esotropia, left eye |
|
H50.32 |
Intermittent alternating esotropia |
|
H50.331 |
Intermittent monocular exotropia, right eye |
|
H50.332 |
Intermittent monocular exotropia, left eye |
|
H50.34 |
Intermittent alternating exotropia |
|
H50.40 |
Unspecified heterotropia |
|
H50.411 |
Cyclotropia, right eye |
|
H50.412 |
Cyclotropia, left eye |
|
H50.42 |
Monofixation syndrome |
|
H50.43 |
Accommodative component in esotropia |
|
H50.51 |
Esophoria |
|
H50.52 |
Exophoria |
|
H50.53 |
Vertical heterophoria |
|
H50.54 |
Cyclophoria |
|
H50.55 |
Alternating heterophoria |
|
H51.0 |
Palsy (spasm) of conjugate gaze |
|
H51.11 |
Convergence insufficiency |
|
H51.12 |
Convergence excess |
|
H51.8 |
Other specified disorders of binocular movement |
|
H52.511 |
Internal ophthalmoplegia (complete) (total), right eye |
|
H52.512 |
Internal ophthalmoplegia (complete) (total), left eye |
|
H52.513 |
Internal ophthalmoplegia (complete) (total), bilateral |
|
H52.521 |
Paresis of accommodation, right eye |
|
H52.522 |
Paresis of accommodation, left eye |
|
H52.523 |
Paresis of accommodation, bilateral |
|
H52.531 |
Spasm of accommodation, right eye |
|
H52.532 |
Spasm of accommodation, left eye |
|
H52.533 |
Spasm of accommodation, bilateral |
|
H53.011 |
Deprivation amblyopia, right eye |
|
H53.012 |
Deprivation amblyopia, left eye |
|
H53.013 |
Deprivation amblyopia, bilateral |
|
H53.021 |
Refractive amblyopia, right eye |
|
H53.022 |
Refractive amblyopia, left eye |
|
H53.023 |
Refractive amblyopia, bilateral |
|
H53.031 |
Strabismic amblyopia, right eye |
|
H53.032 |
Strabismic amblyopia, left eye |
|
H53.033 |
Strabismic amblyopia, bilateral |
|
H53.30 |
Unspecified disorder of binocular vision |
|
H53.32 |
Fusion with defective stereopsis |
|
H53.33 |
Simultaneous visual perception without fusion |
|
H53.34 |
Suppression of binocular vision |
|
H55.01 |
Congenital nystagmus |
|
H55.02 |
Latent nystagmus |
|
H55.03 |
Visual deprivation nystagmus |
|
H55.81 |
Saccadic eye movements |
|
H55.82 |
Deficient smooth pursuit eye movements |
|
H55.89 |
Other irregular eye movements |