Ophthalmology and Optometry Coding Alert

Please Payers With Proper Low-Vision Therapy Coding

Published on Sun Dec 01, 2002

CMS' recent reiteration of the 2000 decision to cover rehabilitation services for Medicare beneficiaries with vision impairment gives coders a second chance to learn the diagnosis and procedure codes covered for low-vision therapy.

The 2002 CMS low-vision therapy coverage policy alerts Medicare contractors to follow the law and pay occupational therapists and other rehabilitation practitioners for medically necessary care, according to the American Occupational Therapy Association.

Prior to the May 29 low-vision therapy policy release, low-vision therapy by any provider did not fall under Medicare coverage in more than 25 states, according to the American Academy of Ophthalmology.

Here's how you can make the most of your low-vision therapy claims in just three easy steps.

The first step to clean claims for low-vision therapy is documentation of the initial assessment of the cause and severity of the patient's vision loss. This documentation must include a record of the patient's potential for functional restoration or improvement.

Next, you must convert this documentation into an ICD-9 code. "We use the whole range of diagnosis codes available," says Harvey Richman, MD, practicing optometrist with Shore Family Eyecare in Manasquan and chairman of the Low Vision Committee in New Jersey.

The following diagnoses, though, are the only ones that constitute medical necessity for coverage of the therapeutic procedures payable by Medicare, according to CMS:

368.41 Scotoma involving central area

368.45 Generalized contraction or constriction

368.46 Homonymous bilateral field defects

368.47 Heteronymous bilateral field defects

369.01 BE (Better eye), total impairment; LE(Lesser eye), total impairment

369.03 BE, near-total impairment; LE, total

369.04 BE, near-total impairment; LE, near-total

369.06 BE, profound impairment; LE, total

369.07 BE, profound impairment; LE, near-total

369.08 BE, profound impairment; LE, profound

369.12 BE, severe impairment; LE, total

369.13 BE, severe impairment; LE, near-total

369.14 BE, severe impairment; LE, profound

369.16 BE, moderate impairment; LE, total

369.17 BE, moderate impairment; LE, near-total

369.18 BE, moderate impairment; LE, profound

369.22 BE, severe impairment; LE, severe

369.24 BE, moderate impairment; LE, severe

369.25 BE, moderate impairment; LE, moderate.

CMS defines the levels of visual impairment as the following: moderate best corrected visual acuity is less than 20/60; severe best corrected visual acuity is less than 20/160, or visual field is 20 degrees or less; near-total best corrected visual acuity is less than 20/400, or visual field is 10 degrees or less; and total no light perception.

After establishing a primary diagnosis that establishes medical necessity for vision-impairment therapy, your third step is to examine the documented detailed treatment plan to identify the corresponding CPT code.

"We primarily use 97535 (Self-care/home management training ...) 70 to 75 percent of the time for patients presenting for low-vision therapy," Richman says.

According to Richman, CPT codes 97535 and 97537 are used most often because they restore patients' self-care functions and those functions necessary for patients who are employed, respectively.

Before choosing a procedure code for Medicare patients, be sure the written treatment plan was established by a Medicare physician and implemented by approved Medicare providers, rehabilitation programs/services, e.g., mobility, activities of daily living, and other medically necessary rehabilitation goals. The time frame for rehabilitation to improve the patient's condition must also be predicted.

Arkansas Medicare Services gives the example of a person with an ICD-9 diagnosis of 369.08 (Profound impairment, both eyes ...) that would be eligible for covered rehabilitation services under CPT code 97535, self-care and management training.

The following is a list provided by CMS of examples of therapeutic procedures that with the proper diagnosis codes are considered medically necessary:

97110 Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility

97116 ... gait training (includes stair climbing)

97532 Development of cognitive skills to improve attention, memory, problem solving, (includes compensatory training), direct (one-on-one) patient contact by the provider, each 15 minutes

97533 Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) patient contact by the provider, each 15 minutes

97535 Self-care/home management training (e.g., activities of daily living and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment) direct one-on-one contact by provider, each 15 minutes

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

Coders, beware: This is not a comprehensive list of medically necessary services and therefore is not meant to limit the provision of other medically necessary services, according to CMS.