Ophthalmology and Optometry Coding Alert

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

The 2002 CMS 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, according to the American Academy of Ophthalmology. 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, MD, practicing optometrist with Shore Family Eyecare in Manasquan and chairman of the Low Vision Committee in New Jersey. The following diagnoses, though, are the only ones that constitute medical necessity for coverage of the therapeutic procedures payable by Medicare, according to CMS: 368.41 Scotoma involving central area 368.45 Generalized contraction or constriction 368.46 Homonymous bilateral field defects 368.47 Heteronymous bilateral field defects 369.01 BE (Better eye), total impairment; LE(Lesser eye), total impairment 369.03 BE, near-total impairment; LE, total 369.04 BE, near-total impairment; LE, near-total 369.06 BE, profound impairment; LE, total 369.07 BE, profound impairment; LE, near-total 369.08 BE, profound impairment; LE, profound 369.12 BE, severe impairment; LE, total 369.13 BE, severe impairment; LE, near-total 369.14 BE, severe impairment; LE, profound 369.16 BE, moderate impairment; LE, total 369.17 BE, moderate impairment; LE, near-total 369.18 BE, moderate impairment; LE, profound 369.22 BE, severe impairment; LE, severe 369.24 BE, moderate impairment; LE, severe 369.25 BE, moderate impairment; LE, moderate. 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 97535 (Self-care/home management training ...) 70 to 75 percent of the time for patients presenting for low-vision therapy," Richman says. According to Richman, CPT codes 97535 [...]