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Optometry Coding & Billing Alert

Please Payers With Proper Low-Vision Therapy Coding

Published on Tue Apr 01, 2003

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

The Centers for Medicare and Medicaid Services' 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, experts say.

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, FAAO, FCOVD, practicing optometrist with Shore Family Eyecare in Manasquan and Chair of the Low-Vision Committee in New Jersey.

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

  • Scotoma central area
  • Generalized contraction or constriction
  • Homonymous bilateral field defects
  • Heteronymous bilateral field defects
  • BE (Better Eye), total impairment; LE (Lesser Eye), total impairment
  • BE, near-total impairment; LE, total impairment
  • BE, near-total impairment; LE, near-total impairment
  • BE, profound impairment; LE, total impairment
  • BE, profound impairment; LE, near-total impairment
  • BE, profound impairment; LE, profound impairment
  • BE, severe impairment; LE, total impairment
  • BE, severe impairment; LE, near-total impairment
  • BE, severe impairment; LE, profound impairment
  • BE, moderate impairment; LE, total impairment
  • BE, moderate impairment; LE, near-total impairment
  • BE, moderate impairment; LE, profound impairment
  • BE, severe impairment; LE, severe impairment
  • BE, moderate impairment; LE, severe impairment
  • BE, moderate impairment; LE, moderate impairment

    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 the 97535 - 70-75 percent of the time - for patients presenting for low-vision therapy," Richman says. According to Richman, CPT codes 97535 and 97537 (Self-care/home management training; and Community/work reintegration training) 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, be sure the treatment plan was established by a Medicare-approved physician, implemented by a Medicare-approved provider(s), and included all rehabilitation programs/services, i.e., mobility, activities of daily living, and other medically necessary rehabilitation goals. You must also predict the time frame for rehabilitation to improve the patient's condition.

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

     

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