Effective Date: July 25, 2021
Last Updated: August 22, 2021

Purpose:
To provide guidelines for multiple diagnostic ophthalmology procedure reductions to eligible services. This policy applies to professional providers.

Scope:
Products included:

• NJ FamilyCare/Medicaid
• Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP)

Definitions:

• Multiple Diagnostic Ophthalmology Procedures: Procedure codes listed on the National Medicare Physician Fee Schedule Database (MPFSD) with a multiple procedure indicator of ‘7’

Policy:
In accordance with CMS guidelines, Horizon NJ Health shall reimburse the primary procedure at 100% of the applicable Horizon NJ Health fee schedule. Secondary procedures shall be reimbursed at 80% of the technical component value and 100% of the professional component value.

Limitations and Exclusions:
Notwithstanding the foregoing, all payment determinations are subject to all other, applicable limitations, including but not limited to, the following:

• Benefit Limitations;
• The terms of any applicable provider participation agreement;
• Routine claim editing logic, including but not limited to incidental or mutually exclusive logic;
• Medical necessity; and
• Applicable law, regulatory guidance, government mandates, and the terms of the Managed Care Contract between Horizon NJ Health and the New Jersey Department of Human Services, Division of Medical Assistance and Health Services.

References:
American Medical Association, Current Procedural Terminology (CPT®) Professional Edition and associated publications and services

CMS Manual System, Transmittal 1149 “https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1149OTN.pdf”
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1149OTN.pdf

History: