An Update on Reimbursement for Vision Rehabilitation
The necessity of an occupational therapist in your practice.
BY LYLAS MOGK, M.D.

Rehabilitation for the blind and visually impaired got its jumpstart during World War II when young, newly blinded or visually impaired veterans needed jobs and life skills retraining. Blind rehabilitation moved into civilian life in the '60s with the onset of retinopathy of prematurity, in which premature babies were blinded by the oxygen that saved their lives. Blind rehabilitation services were provided through government and school programs, as well as by some private, nonprofit agencies. These services were conducted outside the medical system and the college- and university-trained professionals supplying them were not medically credentialed.

Vision rehabilitation has come to the fore in the last decade as AMD dramatically changed the demographics of visual impairment and escalated the numbers dramatically. However, the existing system for rehabilitation of the blind and visually impaired was designed to serve small numbers of young, completely blind or severely visually impaired persons, whose needs are different from those of partially sighted seniors. Blind rehabilitation services often require legal blindness (20/200), which is not appropriate to those with gradual, progressive loss, who need rehabilitation as soon as function is impaired.

Gaining Medicare Coverage

This mismatch of services to needs prompted ophthalmologists to bring the emerging field of vision rehabilitation into rehabilitation medicine and gain Medicare coverage for it. In May of 2002, after a series of regional policies adopted between 1997 and 2002 had extended coverage to 28 states, CMS published a Memorandum in Vision Rehabilitation confirming vision rehabilitation as a covered service. Beneficiaries include those with acuities of 20/70 or less, central scotomas or field deficits. Services are provided by an occupational therapist by order of a physician or another individual working under the direct supervision of the physician and billing incident-to the physician. While anyone designated by the physician could provide rehabilitation services, including rehabilitation teachers (recently renamed vision rehabilitation therapists), orientation and mobility specialists, and even trained ophthalmic technicians, only occupational therapists could conduct the training in sites distant from the physician, for example in patients' homes.

Before this Memorandum was published, bills had been presented to Congress to gain national CMS coverage for vision rehabilitation and to gain CMS recognition for the three groups of nonmedical professionals: certified vision rehabilitation therapists, low-vision therapists and orientation and mobility specialists. With the publication of the 2002 Memorandum granting national coverage and incident-to-billing privileges, the bills remained, with the goals of making that coverage irreversible and creating a new category of general supervision for nonmedical professionals, which would enable them to work with patients at sites distant from the physician. The American Academy of Ophthalmology (AAO) has supported these bills. Congress acted on the bills by mandating a CMS Demonstration Project in Vision Rehabilitation to study the impact of adding the three groups of nonmedical professionals as CMS suppliers of services in patients' homes as well as in offices, clinics or agencies.

Project in Jeopardy: Part 1

This was the relatively happy state of affairs — ophthalmologists could offer vision rehabilitation services by an occupational therapist or by another designated individual under direct supervision and billing incident-to the physician — until May 2005. Within 2 weeks of each other, two unrelated events occurred that month which changed the ground rules for vision rehabilitation and threaten to jeopardize its quality and future.

First, CMS ruled that rehabilitation codes for any impairment can only be used by physicians, physical therapists, speech therapists and occupational therapists, thus eliminating incident-to billing for vision rehabilitation services by nonmedical professionals, as well as ophthalmic technicians. It is believed that the ruling was instigated by an organization of physical therapists to exclude athletic trainers from their turf, but vision rehabilitation was caught in its net, without prior notice. An initial suit by the Athletic Trainers Association was dismissed for lack of jurisdiction, but another is under preparation.

AAO Requests an Exemption for Visual Impairment Codes

The AAO and its SmartSight Taskforce have requested an exemption to the ruling for visual impairment codes, as these codes are the exclusive purview of vision rehabilitation and would affect no other specialties. CMS has not responded, as of this writing. Until and unless there is an exemption for vision rehabilitation, ophthalmologists who wish to provide vision rehabilitation services must now hire an occupational therapist or refer to an OT in independent practice. A possible exception is that a nonmedical vision rehabilitation professional or a trained ophthalmic technician might offer brief, but important basic training in lighting, contrast and application of devices, billed by the physician under the E&M technician code 99211, which pays far less than rehabilitation codes. This is a reasonable, though untested, use of this code.

Effects of the CMS Ruling

The incident-to ruling is a disservice to visually impaired CMS beneficiaries who need rehabilitation, and to the field of vision rehabilitation whose professionals have included the three nonmedical groups. Its immediate impact is felt by a number of ophthalmology practices that have employed certified low-vision therapists or other nonmedical professionals to provide vision rehabilitation services since the 2002 Memorandum, and its further impact will be felt in the absence of services that otherwise may have been developed. If it stands, it is hoped that occupational therapy will rise to the challenge and meet its responsibility to serve the visually impaired population by including vision rehabilitation training in standard curricula and providing specialty graduate training on a broad basis. Occupational therapists who do have this training are exceptionally good at working with seniors, as they are well versed in medical and functional conditions unrelated to vision that may complicate the vision loss. Hopefully, some nonmedical vision rehabilitation professionals will be inspired and able to complete a Masters degree in occupational therapy and bring the combined expertise to the field of vision rehabilitation.

Project in Jeopardy: Part 2

The second event of concern occurring in May 2005 was the publication of the CMS Demonstration Project guidelines, whose provisions threaten the very future of vision rehabilitation services for those with adult-onset visual impairments. The most egregious provisions include:

The limit of rehabilitation service to a maximum of 6 hours, regardless of the patient's needs or rehabilitation potential.

Such a restriction is unique in all of rehabilitation medicine, whose guidelines, as adopted in the 2002 Memorandum on Vision Rehabilitation, allow a maximum of 3 consecutive months of service, with specific number of hours and content of service based on the therapist's judgment and the patients needs, goals and progress.

The exclusion of certified occupational therapy assistants, who are recognized medical service suppliers,

The denial of services to beneficiaries who reside outside the demonstration areas but who would otherwise receive services within these areas, and

The assessment of impact of vision rehabilitation by counting admissions to area emergency rooms for falls and by patient satisfaction questionnaires.

This is an indicator that ignores the realities that many patients who fall do not present to emergency rooms and that, in the absence of vision rehabilitation or sufficient vision rehabilitation, many adults with visual impairments stop walking for fear of falling. In addition, there are other risks to health and well being that exceed those of falling, for example: medication mix-ups, poor nutrition, social isolation and depression.

The guidelines also ignore the reality that patients' satisfaction with limited services may be based on lack of awareness of their real potential for independent function if they were to receive comprehensive training.

Poor Guideline Development

The guidelines were developed without expert consultation in the practice of outcomes assessment of vision rehabilitation and without consideration of the standard of practice in vision rehabilitation. Rather, they were based solely on financial considerations, as the Demonstration Project is an underfunded Congressional mandate. Unfortunately, the project planners opted for redefining the standard of care in vision rehabilitation to save money, rather than instituting design measures to accommodate vision rehabilitation as it is responsibly practiced.

Recommended Changes

The AAO and its SmartSight Taskforce have submitted an analysis of the impact of the guidelines and specific recommendations and the American Occupational Therapy Association has submitted similar documents. The recommended revisions would allow the Demonstration Project to be carried out within its budget, but without reducing the standard of care of vision rehabilitation or jeopardizing its assessment of impact.

Demonstration Project costs could be conserved by limiting the study timeframe to 3 years instead of the proposed 5 years, by reducing the number of demonstration sites and by allowing the services of occupational therapists within the demonstration areas to be reimbursed as usual by their local carriers. The Demonstration Project, as currently designed, unnecessarily assumes those costs, which CMS is already covering under another budget. The funds conserved could then be used for services that are consistent with the standard of care.

With regard to assessment of impact, the Demonstration Project was established to determine the feasibility and impact of adding new suppliers or services.  It was not meant to be an outcomes study of vision rehabilitation.  The measure of impact by admissions to emergency rooms for falls should be deleted and instead the number of additional patients served should be tabulated.  IF patient questionnaires are to be used, the questions and protocol for administration should be developed in consultation with experts in vision rehabilitation outcomes.

What Now?

The Demonstration Project was scheduled to begin the fall of 2005 and run for 5 years in selected areas not yet announced.  IT appears that the start will be delayed until January 2006, but it is not known at this time whether the guidelines will be revised before that time, or at all.  The good news is, that within the demonstration areas the incident-to ruling will be suspended such that nonmedical vision rehabilitation professionals will be permitted to provide services under the general supervision of a physician.  Occupational therapists will have the same privileged and parameters of practice as they have now nationwide.