Ophthalmology and Optometry Coding Alert

CMS tests the waters for full low-vision rehabilitation reimbursement

If your practice includes ophthalmologists who supervise vision rehabilitation therapists, do you know the ICD-9 codes or the new HCPCS codes you need to qualify for a new Medicare demonstration program?

Starting April 3, low-vision rehabilitation professionals in New Hampshire, North Carolina, Atlanta, Kansas, Washington state and all five boroughs of New York City will be able to bill Medicare for vision rehabilitation services under the general supervision of an optometrist or ophthalmologist.

Look for New Low-Vision Codes

The October 2005 update to the Medicare Physician Fee Schedule included four new temporary demonstration procedure codes, G9041-G9044 (Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands ...), corresponding to the type of professional providing the service:

• qualified occupational therapists: G9041
• certified orientation and mobility therapists: G9042
• certified low-vision rehabilitation therapists: G9043
• certified low-vision rehabilitation therapists: G9044.

Medicare has not assigned relative value units to these codes yet. These professionals must work under the general supervision of an optometrist or ophthalmologist, meaning that the physician "does not need to be on the premises nor in the immediate vicinity of the rehabilitation services," Medicare says.

The procedures are furnished under the ophthalmologist's overall direction and control, but the ophthalmologist's presence is not required during the procedure, says April Gentry, CCS-P, OCS, medical coder at the Eye Clinic of Fairbanks, Alaska. The training of the nonphysician personnel who perform the rehabilitation services and the maintenance of the necessary equipment and supplies is the continuing responsibility of the ophthalmologist.

Medicare announced the demonstration program in June 2005. The agency announced the implementation date of April 3, 2006, and made some revisions and corrections to the project, in transmittal 37, dated Jan. 20, 2006. The demonstration project, which CMS plans to run for five years through March 2011, will "cover low-vision rehabilitation services to people with a diagnosis of moderate or severe vision impairment not correctable by conventional methods of spectacles or surgery."

Previously, such rehabilitative services must have been provided directly by a physician, or a qualified physical or occupational therapist.

Prove Medical Necessity With 'Severe Impairment'

ICD-9 codes that Medicare carriers will accept as supporting medical necessity for these services will be:

• 368.41--Scotoma involving central area
• 368.45--Generalized visual field contraction or constriction
• 368.46--Homonymous bilateral field defects
• 368.47--Heteronymous bilateral field defects
• 369.01-369.08--Profound impairment, both eyes
• 369.12-369.18--Moderate or severe impairment, better eye, profound impairment lesser eye
• 369.22-369.24--Moderate or severe impairment, both eyes.

To correctly assign the 369.xx ICD-9 codes, follow Medicare's definitions of the levels of vision impairment:

• Moderate visual impairment: Best corrected visual acuity less than 20/60 in the better eye

• Severe visual impairment (legal blindness): Best corrected visual acuity less than 20/160, or visual field diameter 20 degrees or less

• Profound visual impairment: Best corrected visual acuity less than 20/400, or visual field 10 degrees or less

 • Near-total visual impairment (severe blindness): Best corrected visual acuity less than 20/1000, or visual field 5 degrees or less

• Total visual impairment (total blindness): No light perception.

To learn more, download an information sheet from Medicare at http://www.cms.hhs.gov/ContractorLearningResources/downloads/JA3816.pdf.