Bulletin 230804 — Update: Implementation of the new Optometry Services Agreement

Overview of claims processing changes effective September 1, 2023

To: Optometrists
Category: Optometrist Services
Written by: Claims Services Branch, Health Programs and Delivery Division
Date issued: August 30, 2023
Bulletin Number: 230804

Background

The Ministry of Health (ministry) and the Ontario Association of Optometrists (OAO) have been working together to implement changes to the Ontario Health Insurance Plan (OHIP) Schedule of Benefits for Optometry Services in accordance with the new Optometry Services Agreement.

As described in INFOBulletin 230311, adjustments to the affected fee schedule codes come into effect September 1, 2023. The final phase of changes to the Schedule of Benefits for Optometry Services involves the creation of new fee codes as well as revised descriptions and payment requirements for existing fee schedule codes that have been amended.

This bulletin outlines claims handling instructions to assist optometrists with payment of OHIP insured optometry services.

Revised definitions and fee codes

Revisions to fee schedule code descriptions have been made to eligible medical conditions. Payment requirements have also been made to various fee codes.

Eligible medical conditions

The definition of eligible medical conditions has been updated in alignment with the changes in the Schedule of Benefits for Optometry Services.

• Glaucoma requiring or having had treatment with medication, laser (excluding prophylactic laser peripheral iridotomy), or surgery
• Cataracts / posterior capsular opacification with a visual acuity of 20/40 or worse in the best corrected eye, or when a surgery referral is made
• Retinal disease that is acute, or is chronically progressive
• Corneal disease that is acute, or is chronically progressive
• Uveitis that is acute or chronic, during episodes of active inflammation
• Optic pathway disease that is acute, or is chronically progressive
• Acquired cranial nerve palsy resulting in strabismus during the acute phase or until the condition resolves or stabilizes
• Ocular drug toxicity screening for patients taking hydroxychloroquine, chloroquine, ethambutol or tamoxifen
• Diabetes mellitus

See Table 1 for a list of diagnostic codes that should be applied when submitting claims for payment.

Table 1: List of Diagnostic Codes for eligible medical conditions

Seniors ages 65 years and older

Major oculo-visual examinations

Patients aged 65 years or older with no eligible medical conditions may receive a major oculo-visual examination once per 18-month period. Please submit the claim using existing fee code V406A.

Patients aged 65 years or older with one or more eligible medical conditions may receive a major oculo-visual examination once per 12-month period. Please submit a claim using new fee code V407A.

Related Explanatory Codes

If a claim for V406A is submitted with a diagnostic code for an eligible medical condition, it will automatically be changed to a V407A with the explanatory code ‘VN – Allowed as Major oculo-visual exam for seniors with medical condition’.

If a claim for a major oculo-visual examination is submitted before the applicable 12- or 18-month period, it will pay at $0.00 with explanatory code ‘V5 – Only 1 Major Oculo-Visual Examination allowed in a 12-month period for under 19 or over 65 with medical condition; 1 in 18-month period for over 65 without medical condition’.

Oculo-visual minor assessments

Minor assessment claims for these patients should use fee code V415A.

Seniors with no eligible medical conditions

A maximum of two minor assessments are payable per 18-month period following the major oculo-visual assessment (fee code V406A) for a patient with no eligible medical conditions.

Seniors with one or more eligible medical conditions

A maximum of two minor assessments are payable per 12-month period following the major oculo-visual assessment (fee code V407A) for a patient with one or more eligible medical conditions.

Please note: if the limit of fee code V415A has been met in the applicable 12- or 18-month eligibility period, through services rendered by any optometrist, additional claims submitted for V415A will pay $0.00 with explanatory code ‘M1 – Maximum fee allowed or maximum number of services has been reached by same/any provider’.

A claim for fee code V415A will pay at $0.00 with explanatory code ‘VM – Oculo-visual minor assessment is only allowed within eligibility period after a Major Oculo-Visual Examination’ if there is no major oculo-visual examination on history in the preceding applicable 12- or 18-month eligibility period.

Adults 20 to 64 years of age

Major oculo-visual examinations for adults

Claims are only eligible for payment when patients ages 20 to 64 years have an eligible medical condition. Please use fee code V409A.

Major oculo-visual examinations will no longer be eligible for OHIP payment with a requisition (Form # 4347-84 – Request for Major Eye Examination) from a physician or nurse practitioner.

Oculo-visual minor assessments

A maximum of two minor assessments are eligible for payment within the 12-month period following a major oculo-visual examination, and only if this service was provided by an optometrist for patients with one or more eligible medical conditions. Please use fee code V408A.

Please note: to be eligible for payment, fee code V408A must be submitted with a diagnostic code for an eligible medical condition. The diagnostic code submitted does not have to match the diagnostic code used to claim fee code V409A, but the patient’s eligible medical condition must have been present at the time fee code V409A was claimed.

Related Explanatory codes:

1. If a V409A is not approved on history, the claim will approve at $0.00 with explanatory code ‘VM – Oculo-visual minor assessment is only allowed within eligibility period after a Major Oculo-Visual Examination’.
2. Additional claims for V408A submitted in the eligibility period will be rejected with explanatory code ‘M1 – Maximum fee allowed or maximum number of service has been reached same/any provider’.

Automated visual field assessment

The automated visual field assessment (fee code V410A) service is insured when it is clinically necessary to determine the extent and sensitivity of a patient’s visual fields if they have the following medical conditions:

• Retinal disease (including diabetic retinopathy)
• Glaucoma
• Active optic pathway disease
• Ocular drug toxicity screening
• Acquired cranial nerve palsy resulting in strabismus

Only those diagnostic codes listed in Table 2 should be applied when submitting claims for payment.

Table 2: Eligible conditions for automated visual fields assessment

Please note: a claim using fee code V410A may be submitted for a service provided to the patient on the same day or a different day as a major oculo-visual examination (fee codes V404A, V407A, V409A) or oculo-visual minor assessment (fee codes V402A, V408A, V415A).

Complexity modifiers

Three new complexity modifiers have been added to the Schedule effective September 1, 2023.

Glaucoma complexity premium

A glaucoma complexity premium has been created using fee code V411A. It is eligible for payment when caring for patients diagnosed with glaucoma and must be submitted with the same date of service as a Major Oculo-Visual examination (fee codes V404A, V407A, V409A), and diagnostic code ‘365 – Glaucoma’

Child cycloplegic refraction complexity premium

A child cycloplegic refraction complexity premium for patients aged 15 years old or younger has been created. Fee code V412A is eligible for payment for paediatric patients requiring manual cycloplegic refraction and must be submitted with the same date of service as a major oculo-visual examination (fee code V404A) or minor oculo-visual assessment (fee code V402A).

Claims for payment using fee code V412A may be submitted with the diagnostic code ‘378 – Strabismus’ or ‘368 – Amblyopia’.

Please note that claims submitted for patients aged 16 years old or older will reject to the error report with explanatory code ‘A2A – Patient is underage or overage for this service code’.

Diabetes complexity premium

A diabetes complexity premium may be claimed using fee code V413A for patients with ocular complications due to diabetes. V413A must be submitted with the same date of service as a major oculo-visual examination (V404A, V407A, V409A) and must be submitted with the diagnostic code ‘248 – Diabetes Mellitus with ocular complications’.

Claims processing of complexity modifiers

Only one complexity modifier (V411A, V412A, or V413A) is payable per patient, per 12-month period. Claims for services in excess of this limit will reject with ‘M1 – Maximum fee allowed or maximum number of services has been reached by same/any provider’.

If a complexity modifier is submitted without a corresponding oculo-visual examination provided on the same service date, it will pay at $0.00 with explanatory code ‘DF – Corresponding fee code was not billed or paid at zero’.

It is recommended that the complexity modifier is submitted on the same claim as the corresponding oculo-visual examination.

If a complexity modifier is submitted with a diagnostic code other than the applicable diagnostic code for the modifier as described above, it will reject with error code ‘V16 –Unacceptable Diagnostic Code’.

If the corresponding oculo-visual examination is submitted with a diagnostic code other than the applicable diagnostic code for the complexity modifier, the complexity modifier will pay at $0.00 with explanatory code ‘VX – Complexity premium not applicable to visit fee’.

Example: A claim for a major oculo-visual examination (fee code V404A) is submitted with a diagnostic code ‘248 – diabetes’, and for a child cycloplegic refraction complexity premium (fee code V412A) with a diagnostic code ‘378 – strabismus’. The V412A will pay at $0.00 with explanatory code VX.

Claims submission instructions for all optometry codes

All optometry codes must be submitted with a valid diagnostic code.

If a valid diagnostic code is not submitted, the claim will be rejected to the error report with the following error conditions:

• ‘V16 – Unacceptable Diagnostic Code’ when the diagnostic code does not match an eligible condition.
• ‘V21 – Diagnostic Code Required’ when the diagnostic code is missing.
• ‘V22 – Invalid Diagnostic Code’ when the diagnostic code is not on the ministry table of acceptable codes.

Health card validation and time limited codes

Fee code V407A for major oculo-visual examination for seniors has been added to the list of fee codes that can be validated through the ministry’s Health Card Validation system.

As with existing codes, a response of ‘101 – No information available’ will be returned if there is no information to report on the time limited code being validated.

A code of ‘201- Oculo-visual assessment or eye exam performed’ and the service date will be returned if the patient has already had their major oculo-visual examination, by any provider, in the preceding 12-month period.

Fee code V406A has been amended to return a code of 201 and the service date if the patient has already had their major oculo-visual examination, by any provider, in the preceding 18-month period.

Optometrists will continue to be able to use to Health Card Validation to check the service eligibility for major oculo-visual examination for patients age 19 years or less (V404A) and major oculo-visual examination for patients age 20 to 64 years (V409A).

Reminder that ‘101- No information available’ may be returned if validating an incorrect code for the patient’s age. Please ensure you validate the correct code based on patient eligibility for that code, to obtain complete information and ensure correct payment.

Keywords/Tags

Optometry Services Agreement; optometrists; V404; V406; V407; V408; V409; V410; V411; V412; V413; V415; appropriateness; negotiations; optometry schedule; time limited; HCV

Contact information

Do you have questions about this INFOBulletin? Email the Service Support Contact Centre or call 1-800-262-6524. Hours of operation: 8:00 a.m. to 5:00 p.m. Eastern Monday to Friday, except holidays.