Ophthalmology and Optometry Coding Alert

Vision rehabilitation, a growing field that presents many coding challenges for ophthalmologists and optometrists, has three main coding components:
 
1. The initial consultation to evaluate the problem, alternative treatments, and the patient's readiness for treatment
 
2. A series of possible diagnostic tests to explore the extent of the problem (i.e., where blind spots are)
 
3. The therapy.

Of the 3.5 million visually impaired Americans, many are Medicare beneficiaries. In fact, 21 percent of adults age 65 and older are affected by this condition, which is not correctable with eyewear. Low vision reduces the ability to function and can cause harm to a patient who may fall, suffer burns, confuse medications, or become injured in another way due to loss of sight. Visual rehabilitation therapy can help patients see and function, so lawmakers and the American Association of Ophthalmologists have been pushing Medicare to require coverage.
 
Some carriers cover vision rehabilitation. Many recognize that teaching people to function independently makes business sense; it costs less than more long-term assistance. But payment for vision rehabilitation, also known as low-vision therapy, by those carriers that cover it falls under close scrutiny for proper coding.
 
"Low vision is in the early stretch," says John Pinto, an ophthalmology consultant based in San Diego. He says that some carriers' recent decisions to cover low vision clearly make the treatment more appealing to a broad cross-section of ophthalmologists.
 
Carriers that cover vision rehabilitation require that surgical repair be considered first. However, for many causes of low vision, such as macular degeneration, the only surgery is laser treatment with Visudyne, which may not be effective and doesn't last. Document previous attempts at treatment, and indicate the level of success of these treatments.
 
Cahaba GBA, the Medicare carrier in Georgia, published a comprehensive LMRP for visual rehabilitation in August 2001. The LMRP requires an initial visit for low vision to document the cause of the disability, determine the degree of impairment, test functional ability for rehabilitation, and set a treatment plan.
 
In vision rehabilitation, the provider focuses on increasing the use of the remaining vision. There is no specific code or code set for vision rehabilitation. The ophthalmologist or optometrist must select the codes that are most appropriate.

Many physicians can perform the evaluation, but whether the patient proceeds with the therapy depends on a number of factors particularly the results of diagnostic testing. "We conduct the testing and take the evaluation right up to the point of rehabilitation," says Ron Frame, OD, who practices with Optometric Physicians of Parkersburg, in Parkersburg, W.V.
 
Testing is essential to determine the type and extent of vision impairment. After the initial consultation (99241-99245) or office visit (99201-99215, 92002-92014), the ophthalmologist proceeds to diagnostic tests necessary before low-vision rehabilitation can begin.
 
Note: A mini-mental status exam performed at the initial visit is not separately payable, but included in the E/M visit.
 
Separate payment would be considered for four tests:
 
1. Visual Fields. This tests the extent of vision. The limited exam (92081, visual field examination, unilateral or bilateral, with interpretation and report; limited examination [e.g., tangent screen, Autoplot, arc perimeter, or single stimulus level automated test, such as Octopus 3 or 7 equivalent]) plots blind spots or peripheral loss. The intermediate exam (92082 intermediate examination [e.g., at least 2 isopters on Goldmann perimeter, or semiquantitative, automated suprathreshold screening program, Humphrey suprathreshold automatic diagnostic test, Octopus program 33]) measures full peripheral vision and may involve different methods to document the same thing. The extended exam (92083 extended examination [e.g., Goldmann visual fields with at least 3 isopters plotted and static determination within the central 30 degrees, or quantitative, automated threshold perimetry, Octopus program G-1, 32 or 42, Humphrey visual field analyzer full threshold programs 30-2, 24-2, or 30/62-2]) may involve different methods and also documents these problems.
 
Visual-field tests determine what blind spots or other vision problems a patient has and help justify further testing and treatment, explains Jon Winders, practice administrator for Umpqua Valley Eye Associates in Roseburg, Ore. The patient views different lights in different positions. Patients with macular degeneration, for example, have good peripheral vision and poor central vision.
 
2. Retina Tests. Normally done for retinal problems, an electro-oculogram (ERG) (92270, electro-oculography with interpretation and report) or electroretinogram (EOG) (92275, electroretinography with interpretation and report) may now be done as a diagnostic aid to assess a patient's need for visual rehabilitation. The EOG is not as sensitive as the ERG, but both can assess the retina's response to light.
 
3. Color-Vision Test. A test for color vision (92283, color vision examination, extended, e.g., anomaloscope or equivalent) requires the use of an anomaloscope. This bilateral procedure is normally performed for a broad range of conditions, from neoplasms of the brain (191.0, 225.0, 227.4) to congenital night blindness (368.61) to hereditary optic atrophy (377.16). Using it as a diagnostic aid to evaluate low vision represents a possible new area for this important test.
 
4. Scanning Laser. If you use scanning-laser ophthalmoscopy to define an area of fixation, some carriers ask for 92135 (scanning computerized ophthalmic diagnostic imaging [e.g., scanning laser] with interpretation and report, unilateral) with 368.41 (scotoma involving central area).

An occupational therapist, working under the supervision of an ophthalmologist, is likely to use 97003 (occupational therapy evaluation) when conducting the initial assessment or 97004 for a follow-up evaluation (occupational therapy re-evaluation) of the low-vision patient. The focus is on the patient's ability to perform activities of daily living (ADL).
 
Carriers usually require that the occupational therapy components be established in writing and signed by the ordering ophthalmologist. Describe the type, amount, frequency and duration of services, including the diagnoses and goals.
 
Direct one-on-one contact with the patient is required for therapeutic procedures that may be carried out by the ophthalmologist, optometrist or occupational therapist.
 
When there is no progress in treatment on two occasions when a patient plateaus Medicare carriers that pay for such services normally stop covering the procedure. A patient with a restricted visual field, for example, would no longer be covered for 97535 (self-care/home-management training [e.g., activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of adaptive equipment] direct one-on-one contact by provider, each 15 minutes) and 97537 (community/work-reintegration training [e.g., shopping, transportation, money management, avocational activities and/or work-environment/modification analysis, work-task analysis], direct one-on-one contact by provider, each 15 minutes). However, this patient might need 97112 (therapeutic procedure, one or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and proprioception) for visual scanning training; Medicare would cover additional units of 97112 for such a patient. Also covered is 97530 (... therapeutic activities, direct [one-on-one] patient contact by the provider [use of dynamic activities to improve functional performance], each 15 minutes).
 
"We use several devices when we train patients to see with a blind spot, for example," Frame says. "But the problem is partly that it takes a long time to train them and partly that the equipment they would need to read at home is too expensive." Medicare may cover the provider's evaluation and treatment, but it will not pay for the $2,500 screen many patients need to be able to read at home, he explains.
 
Note: Carriers may require that technicians who perform "incident to" services for low-vision treatment have a certification in low vision.

Carriers that cover visual rehabilitation generally require a diagnosis of an impairment that is not correctable by conventional refractive means. These conditions include:
 

368.41 scotoma involving central area 

368.45 generalized contraction or constriction of the field of vision 

368.46 homonymous bilateral visual field defects 

368.47   heteronymous bilateral field defects. 
 
Carriers also cover moderate-to-total vision impairment. Use blindness and low-vision codes (369.00-369.04, 369.06-369.08, 369.11-369.14, 369.16-369.18, 369.22, and 369.24-369.25.)
 
The impairment can be severe, but you must consider both eyes. For example, both eyes can have moderate impairment (best corrected acuity 20/70 to 20/160). Or the better eye can have moderate impairment, and the lesser eye profound (best corrected acuity 20/500 to 20/1000) to near total impairment (best corrected acuity less than 20/1000).

Carriers require that patients need visual rehabilitation, as evidenced by low visual function, i.e., a score of 70 or less on the visual function questionnaire administered by an ophthalmologist, optometrist or technician. Keep the questionnaire in the patient's record.
 
The patient must also express dissatisfaction with current vision. Otherwise, carriers reason, the patient will not be motivated to practice the exercises that are part of low-vision training.
 
For reference, see the comprehensive Cahaba LMRP on low vision at www.gamedicare.com.