Ophthalmology and Optometry Coding Alert

Question: How can we bill and be paid for low-vision evaluations and treatment?

Delaware Subscriber
  
Answer: Although low vision is caused by medical and not refractive problems, Medicare doesn't cover low-vision aids, and therefore it doesn't cover the service to determine what kind of low-vision aids would help the patient. However, Medicare covers the initial consultation in which the ophthalmologist diagnoses the medical condition that causes the low vision.
 
Often, an optometrist or ophthalmologist is already following the patient for ophthalmic problems that eventually lead to low vision. For example, the patient may have macular degeneration or retinitis pigmentosa. When the patient begins to complain that he or she cannot see well enough to perform daily living activities, the optometrist or ophthalmologist typically conducts an examination to evaluate the disease progression and to determine an appropriate treatment plan. The treatment plan may include a recommendation that low-vision aids should be investigated to determine whether they would help the patient in daily living activities.
 
This visit, in which the practitioner determines that the patient should investigate the use of low-vision aids, is covered by Medicare because the medical condition is the reason for the encounter. If the patient was referred to the ophthalmologist by another physician or optometrist to evaluate the disease process, bill this examination as a consultation (99241-99245). If the patient was not referred by an appropriate source but is being seen for the first time, the visit should be coded as a new-patient office visit (99201-99205 or 92002-92004). If the ophthalmologist has been following the patient and recommends low-vision aids, code an established-patient visit (99212-99215 or 92012-92014).
 
Low-vision services typically include reviewing the various activities of daily living that are restricted by the patient's low vision and trying a variety of low-vision aids while instructing the patient on their proper use. Such a service may last an hour or more and is very helpful to patients. Because of the amount of time spent, practitioners believe they should be reimbursed for a visit or the activities-of-daily-living physical therapy code (97535). Unfortunately, billing low-vision service to Medicare may be a problem, and the reason is somewhat complex.
 
To understand the issues, it's important to first distinguish between a visit to assess a medical problem that is resulting in low vision, and a refractive-error visit, which isn't related to a medical problem. Medicare will not reimburse you for a refraction, but it will reimburse you for an examination to assess a medical condition. Low-vision aid services fall somewhere between refractive and medical conditions. The patient has low vision due to a medical condition, but the treatment plan for low-vision is refractive assistance in the form of a low-vision aid.
 
Second, it is important to understand that historically, since the inception of the Medicare program, low-vision aids have not been covered as a benefit. And there has been a longstanding policy of CMS (formerly HCFA) that a service directly related to a noncovered service or supply is not a covered benefit. It is this policy that causes refractive surgery to be noncovered by Medicare, for example.
 
CMS does not have a crystal-clear national policy to guide Medicare carriers on the coverage of low-vision services. Therefore, local Medicare carriers have some leeway in establishing LMRPs. In the absence of an LMRP permitting billing for low-vision service, practitioners would probably be safest to assume that low-vision services are not a benefit.
 
Many coders mistakenly bill consultations or visits. In the absence of an LMRP specifically allowing low-vision services to be billed, you can't bill Medicare at all. Since the aids aren't a Medicare benefit, neither is the service of helping the patient to select the aid. The billing is typically sent to the carrier with the diagnosis describing the type of macular degeneration the patient has. The problem is that the patient is not being seen to treat or evaluate the condition of macular degeneration, and many low- vision examinations do not even have the finding of macular degeneration documented in the medical record.
 
The ophthalmologist can bill the patient directly for assisting the patient in selecting low-vision aids. It's a good idea to set up a dummy code to use internally to track these services. Then, determine a charge for the fitting service.

 
-- Answers to "Reader Questions" and "You Be the Coder" provided by Lise Roberts, vice president of Health Care Compliance Strategies in Jericho, N.Y.; Raequell Duran, president of Practice Solutions in Santa Barbara, Calif.; and Charles McCash, MD, solo practitioner at Children's Eye Center of South Texas in San Antonio, Texas.