Eli's Rehab Report

Most PM&R practices rejoiced when CMS announced it would allow expanded rehabilitation coverage for blind and visually impaired Medicare patients, but this does not mean that anything goes. Visually impaired patients must demonstrate the potential for improvement, and those patients whose therapy is considered "maintenance" will not be covered.

In the recently released program memorandum (AB-02-078), CMS states that it will cover physician-prescribed therapy services for visually impaired and blind patients on the same basis as patients with other conditions that result in reduced functioning. The memo lists examples of applicable PM&R codes, such as activities of daily living (ADL, 97535) and therapeutic procedures (97110). However, therapists should not limit their services to these codes only.

"The program memorandum gives a list of what they deem to be examples of appropriate codes, but remember, [CMS is] not limiting people to those codes," says Doug Peddicord, vice president of Washington Health Advocates, which worked with CMS to achieve the new ruling. "The physician's plan of care should ultimately determine which services are offered to these patients."

Example of Covered Services

As with all rehabilitation services, visually impaired patients must have the potential for significant improvement of lost functions to justify the therapy's medical necessity. For instance, says John Holly, OTR, an occupational therapist at Kingston Therapy in Rhode Island, suppose a diabetes mellitus (250.50-250.53) patient recently lost his sight (369.00-369.9) and will soon be released from a rehabilitation facility to live on his own. The rehabilitation physician prescribes occupational therapy to teach the patient mobility, activities of daily living, and community-reintegration techniques. The service would be coded using both diagnosis codes, with the diabetes diagnosis listed first, followed by the loss of sight ICD-9. The therapist would code the mobility training using either gait training (97116) or therapeutic exercises (97110), the ADL as 97535, and the community-reintegration training as CPT 97537 .

The PM reminds practices that these rehabilitation services should be provided by a physician, an occupational therapist, or a physical therapist as state licensing regulations dictate. If the physician employs the therapist, the therapy should be billed "incident-to" using the physician's identification number.

Example of a Noncovered Service

As with other rehabilitation procedures, Medicare will not cover maintenance therapy because it does not support the objective of patient improvement. For instance, Holly says, suppose a patient with AIDS (042) lost her sight and requires continual help with ADL so she can continue to live alone despite her deteriorating condition. Because the physician and therapist do not expect the patient's condition to improve with therapy, Medicare will not reimburse for these services.

However, Medicare does cover occupational therapy services to establish a maintenance program, which will be carried out by a caregiver.

Therapists should keep in mind that since January 2000, CMS allows optometrists to refer patients for therapy and establish treatment plans, so therapists may start receiving more referrals from optometrists due to the new CMS PM. Some state laws may limit optometrists' scopes of practice, but if there is no such restriction, these referrals can increase access to therapy for these Medicare beneficiaries.

The full text of the program memorandum is available on the CMS Web site.