Ophthalmology and Optometry Coding Alert

Hint: The initial visit may simply involve an E/M code.

When most medical specialty coders think about rehab, they envision a patient performing physical therapy to improve strength or occupational therapy to account for quality-of-life issues. But when it comes to the eye care field, an important type of rehab addresses low vision — and Medicare payers will reimburse you for it, if you know the ropes.

Here’s what it is: Low vision rehabilitation allows people experiencing vision loss to boost their quality of life and sense of independence by getting to know the strategies and techniques that will allow them to function despite their vision limitations.

The Centers for Medicare & Medicaid Services (CMS) began paying for vision rehab 20 years ago, noting, “Medicare beneficiaries who are blind or visually impaired are eligible for physician-prescribed rehabilitation services from approved health care professionals on the same basis as beneficiaries with other medical conditions that result in reduced physical functioning.”

Other payers are likely to reimburse for vision rehab visits as well. However, some eye care coders still aren’t sure how they should be reporting these visits. If that’s the case for your coding team, read on for some best practices that will help you collect for low vision rehab.

Understand the Multi-Step Process

Vision rehabilitation involves two main steps, both of which you should know how to code. However, since no CPT^® code exists to specifically describe low vision rehab, you need to understand what happens at each of the steps:

1. The initial visit to evaluate the problem, alternative treatments, and the patient’s readiness for treatment
2. The therapy sessions

During the initial visit, the eye care specialist should clearly document what the visual impairment is, the patient’s functional imitations, and how/why they would benefit from the rehabilitation program. If the patient has no potential to improve, this service is typically non-payable, so the documentation should always outline what the patient will be able to get out of the rehab service.

In addition, the patient’s file must include a plan of care addressing the goals the patient should be able to meet after the rehab period is over. The plan of care should address how the goals will be assessed, which services will be provided to meet those goals, and approximately how much time it will take to meet the goals and expectations. In addition, the note should state the amount of time spent performing low vision rehab services, and you should maintain measurements of baseline performance along with comparisons of current performance for each session, advises Mary Pat Johnson, COMT, CPC, COE CPMA, senior consultant with Corcoran Consulting Group.

Don’t forget that the attending physician should sign each low vision progress note and see the patient once a month during the therapy period to evaluate the progress and potentially modify the plan of care on an as needed basis. The doctor should sign a discharge summary at the end of the low vision rehab period, describing which plan of care goals were achieved, and the levels of improvement seen.

You Can Perform Diagnostic Tests at Initial Visit

As noted above, the first step in vision rehab services is to see the patient for an initial visit to evaluate the problem. During this visit, Medicare and many other payers will typically pay for diagnostic testing that you perform to evaluate the patient’s condition, in addition to payment for the evaluation itself.

To correctly code for these services, you’ll report the visit using either an evaluation and management (E/M) code, such as 99202-99215 or one of the ophthalmic exam codes (92002- 92004 or 92012-92014).

You’ll also submit a code that describes the tests (if any) your provider performs to evaluate the patient’s vision. These may include the following, among others:

1. Visual fields: This tests the extent of vision and is typically coded using the 92081-92083 (Visual field examination, unilateral or bilateral, with interpretation and report …) range of codes.
2. Retina tests: Normally done for retinal problems, an electro-oculogram (ERG) (92270) or electroretinogram (EOG) (92273-92274) may be done as a diagnostic aid to assess a patient’s need for visual rehabilitation. The EOG is not as sensitive as the ERG, but both can assess the retina’s response to light.
3. Extended color-vision test: A test for color vision (92283) requires the use of an anomaloscope. Extended color vision testing with the Nagel anomaloscope or Farnsworth-Munsell tests (D-15, FM-100) are performed to assess degrees of color discrimination. This bilateral procedure is normally performed for a broad range of conditions, from neoplasms of the brain to congenital night blindness to hereditary optic atrophy. Using it as a diagnostic aid to evaluate low vision represents a possible new area for this important test .
4. Scanning laser: If you use scanning-laser ophthalmoscopy to define an area of fixation, some carriers ask you to report the scanning computerized ophthalmic diagnostic imaging codes (92133-92134).

Look to 97535 in Most Cases for Therapy

The therapist, working under the supervision of an ophthalmologist, is likely to use 97535 (Self-care/home management training (eg, activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment) direct one-on-one contact, each 15 minutes) for the actual therapy. Note that a unit of this code should be reported for every 15 minutes of therapy. So a one-hour session would be reported with four units of 97535 or another appropriate code (such as 97110, 97116, 97533, or 97537).

If the patient stops making progress, the payer is likely to stop covering low vision rehab. For instance, the UnitedHealthcare Medicare Advantage coverage summary states, “A person with profound impairment in both eyes (i.e., best corrected visual acuity is less than 20/400 or visual field is 10 degrees or less) would generally be eligible for, and may be provided, rehabilitation services under 97535. The member must have the potential for restoration or improvement of lost functions in a reasonable amount of time. Most rehabilitation is short-term and intensive, and maintenance therapy – services required to maintain a level of functioning are not covered.”