Mountain State Medical Policy Bulletin

Section: Diagnostic Medical
Number: M-47
Topic: Automated Visual Field Examinations
Effective Date: August 1, 2005
Issued Date: August 1, 2005
Date Last Reviewed: 07/2005

General Policy Guidelines

Indications and Limitations of Coverage

Automated visual field examinations can be performed on patients with no signs or symptoms of disease, and on symptomatic patients to aid in diagnosis or treatment. An automated visual field examination performed in conjunction with a routine eye examination on an asymptomatic patient is considered to be screening and is generally noncovered except for those groups/programs identified in benefits. Automated visual field testing performed in conjunction with a vision examination for prescribing or fitting eyeglasses or contact lenses is not a benefit under the medical-surgical programs.

Automated visual field examinations (92081-92083) are considered medically necessary and payable for the conditions/indications listed in the Text Attachment below.

Automated visual field examinations reported for medical conditions/indications other than those listed in the Text Attachment below will be denied as not medically necessary. A participating, preferred, or network provider is not permitted to bill the patient for these services.

Automated visual field testing that is not covered as a screening test or is not a benefit is not covered.  A participating, preferred, or network provider can bill the member for the denied service.

NOTE:
See Medical Policy Bulletin V-31 for guidelines on manual gross visual field testing (e.g., confrontation testing).

Description

Visual field testing is a process to determine defects in the field of vision and to test the function of the retina, optic nerve, and optic pathways. Visual field testing may be kinetic or static. In kinetic testing (i.e., Goldmann or tangent screen), the stimulus is moved to different areas and the point at which it is first seen by the patient is marked. In static (stationary) perimetry, a specific point is chosen for examination and the stimulus is increased until its threshold is determined. More complex studies with automated and computerized machines can accomplish this type of visual examination.


NOTE:
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Procedure Codes

920819208292083   

Traditional Guidelines

Refer to General Policy Guidelines

FEP Guidelines

Refer to General Policy Guidelines

PPO Guidelines

Refer to General Policy Guidelines

Managed Care POS Guidelines

Refer to General Policy Guidelines

Publications

PRN References

02/200l, Automated visual field testing

References

View Previous Versions

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Table Attachment

Text Attachment

Conditions/Indications

094.81-094.89
095.8
190.0-190.9
191.0-191.9
192.0
192.1
198.4
224.0-224.9
225.0
225.1
227.3
234.0
237.0
237.1
237.70
239.7
239.8
242.00-242.01
242.10-242.11
250.50-250.53
259.8
264.0-264.9
300.11
346.00-346.01
346.10-346.11
346.20-346.21
346.80-346.81
346.90-346.91
348.2
360.23
360.29
361.00-361.07
361.10-361.19
361.2
361.81-361.89
361.9
362.30-362.37
362.40-362.43
362.50-362.57
362.60-362.64
362.70-362.77
362.81-362.89
362.9
363.00-363.08
363.10-363.15
363.20-363.22
363.40-363.43
363.50-363.57
363.61-363.63
363.70-363.72
363.8-363.9
365.00-365.04
365.10-365.15
365.20-365.24
365.31-365.32
365.41-365.44
365.51-365.59
365.60-365.65
365.81-365.89
365.9
368.00-368.03
368.10-368.16
368.2
368.40-368.47
368.60-368.69
368.8-368.9
369.00-369.08
369.10-369.18
369.20-369.25
369.3
369.4
369.60-369.69
369.70-369.76
369.8-369.9
373.8-373.9
374.30-374.34
374.87
376.21-376.22
376.30-376.36
376.40-376.47
376.50-376.52
376.6
376.81-376.89
376.9
377.00-377.04
377.10-377.16
377.21-377.24
377.30-377.39
377.41-377.49
377.51-377.54
377.61-377.63
377.71-377.75
377.9
378.50-378.56
378.81-378.87
379.50-379.59
379.92
431
432.0-432.9
433.00-433.01
433.10-433.11
433.20-433.21
433.30-433.31
433.80-433.81
433.90-433.91
434.00-434.01
434.10-434.11
434.90-434.91
435.0-435.9
436
437.0-437.9
446.5
743.20-743.22
743.51-743.59
743.61
950.0-950.9
951.0
V58.69
V67.51

Procedure Code Attachment


Glossary





This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.

Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Mountain State Blue Cross Blue Shield plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.

Mountain State Blue Cross Blue Shield (MSBCBS) retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of MSBCBS. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.