Coding & Reimbursement

By Suzanne L. Corcoran, COE

Low Vision: What’s Covered?

Who pays what when billing low-vision patients.

Many practices are expanding their services to low-vision patients. In some cases, this includes selecting and fitting low-vision devices. In other cases, a formal low vision rehabilitation (LVR) program is established. Billing for these services can be confusing; here are some aspects to consider.

Q. Does Medicare cover low vision services? Some services are covered while others are not. The initial evaluation of a patient’s condition is covered. The exam itself may not qualify for more than a low level, especially for an established patient, but the proper code to describe the visit may often be determined by duration. These visits are often lengthy and involved, with most of the time the doctor spends with the patient taken up with counseling and advising the patient. For example, an established patient visit that takes 35 minutes, of which more than half is spent counseling, qualifies as code 99214.

Medicare does not cover low-vision aids (e.g., magnifiers), nor the time spent fitting and training patients on the devices. These services should be paid by the patient. When the initial evaluation and counseling of the patient takes place on the same day as the fitting and training, a clear distinction must be made between time spent on covered versus non-covered services. Noting start and stop times is advised.

Q. What is low vision rehabilitation? As of May 2002, Medicare extended its coverage of rehabilitation services to include low vision.

Low vision rehabilitation services may be provided by ophthalmologists and optometrists, or by certified occupational therapists (OT). An OT may be in private practice, employed by a medical group, or associated with a university or other institution. Some states prohibit optometrists from ordering and supervising OT services. When a physician provides LVR, the service must be provided personally or under his or her direct supervision.

Covered services include the initial evaluation by a physician as noted above, as well as a series of therapy sessions. These sessions are usually scheduled weekly and last about an hour. While fitting low-vision devices and training patients in their use are non-covered, teaching patients to modify their behavior while using the devices is included in LVR and covered by Medicare.

Low vision rehabilitation services are considered reasonable and necessary only for patients with a visual impairment, a clear medical need and the potential to benefit from the services. The impairment must not be otherwise correctible (e.g., by surgery or eyeglasses). It must significantly affect the patient’s daily life.

Q. What documentation is required for LVR? The initial assessment must document the specific visual impairment, the functional deficits caused by the impairment and the patient’s ability to benefit from LVR. A written Plan of Care is required. It defines the specific, measurable goals the therapy will meet, the criteria by which the goals will be measured, the services to be directed toward each goal, and a reasonable estimate of the time required to reach the goals. Medical necessity for LVR ends when the patient demonstrates no progress on two consecutive visits.

Each therapy session must include a progress note that includes the actual time spent in LVR services. Monthly progress reports are required to describe progress in meeting the stated goals. Quantitative measurements of progress against stated goals must be included. When a physician provides LVR services, these notes are part of the medical record.

When services are provided by an OT, the attending/ordering physician must promptly review and sign the monthly progress notes. He or she must also see the patient at least every 30 days during therapy and modify the Plan of Care as needed. A detailed discharge summary at the end of LVR is also required.

CPT codes 97535 (self care/management training) and 97537 (community/work reintegration training) are used to describe LVR services. They are billed in 15-minute increments. Please refer to your CPT book for complete descriptions.

This discussion is necessarily an overview. Detailed instructions for LVR are available on your Medicare carrier’s Web site. The CMS publication, MedLearn Matters # MM3816, features additional information. OM