Ophthalmology and Optometry Coding Alert

Question: How can we bill and be paid for low-vision evaluations and treatment?

Delaware Subscriber
  
Answer: Although low vision is caused by medical and not refractive problems, Medicare doesn't cover low-vision aids, and therefore it doesn't cover the service to determine what kind of low-vision aids would help the patient. However, Medicare covers the initial consultation in which the ophthalmologist diagnoses the medical condition that causes the low vision.
 
Often, an optometrist or ophthalmologist is already following the patient for ophthalmic problems that eventually lead to low vision. For example, the patient may have macular degeneration or retinitis pigmentosa. When the patient begins to complain that he or she cannot see well enough to perform daily living activities, the optometrist or ophthalmologist typically conducts an examination to evaluate the disease progression and to determine an appropriate treatment plan. The treatment plan may include a recommendation that low-vision aids should be investigated to determine whether they would help the patient in daily living activities.
 
This visit, in which the practitioner determines that the patient should investigate the use of low-vision aids, is covered by Medicare because the medical condition is the reason for the encounter. If the patient was referred to the ophthalmologist by another physician or optometrist to evaluate the disease process, bill this examination as a consultation (99241-99245). If the patient was not referred by an appropriate source but is being seen for the first time, the visit should be coded as a new-patient office visit (99201-99205 or 92002-92004). If the ophthalmologist has been following the patient and recommends low-vision aids, code an established-patient visit (99212-99215 or 92012-92014).
 
Low-vision services typically include reviewing the various activities of daily living that are restricted by the patient's low vision and trying a variety of low-vision aids while instructing the patient on their proper use. Such a service may last an hour or more and is very helpful to patients. Because of the amount of time spent, practitioners believe they should be reimbursed for a visit or the activities-of-daily-living physical therapy code (97535). Unfortunately, billing low-vision service to Medicare may be a problem, and the reason is somewhat complex.
 
To understand the issues, it's important to first distinguish between a visit to assess a medical problem that is resulting in low vision, and a refractive-error visit, which isn't related to a medical problem. Medicare will not reimburse you for a refraction, but it will reimburse you for an examination to assess a medical condition. Low-vision aid services fall somewhere between refractive and medical conditions. The patient has low vision due to a medical condition, but the treatment plan for low-vision is refractive assistance in the form of a low-vision aid.
 
Second, it is important to understand [...]