Low Vision Coding and Billing Richard Soden, OD, FAAO, CPC. Disclosure Statement Nothing to disclose

Transcription

1 Low Vision Coding and Billing Richard Soden, OD, FAAO, CPC Disclosure Statement Nothing to disclose

2 Concern - Problem It s extremely confusing and frustrating for a visually impaired patient to assess the health care system for help and then determine that low vision services may not be reimbursed under their health care plan including Medicare and managed Medicare?

3 Goal To present a model that will enable providers who render low vision care to appropriately utilize current coding systems for billing low vision rehabilitative services.

4 Key Questions 1. Do Health Insurance Plans (including Medicare and Managed Medicare) cover a low vision exam? 2. Also, do they cover Low Vision Rehabilitation? Yes? No? Maybe?

5 Problems/Concerns Many eyecare practitioners tell their patients that nothing more can be done to improve the functional vision that their patients still have. Medicare does not pay for low vision examinations and devices There is a national Medicare policy on low vision rehabilitation but other insurance carriers do not have similar ones.

6 Need for a Change We need to change the way we think about low vision services as well Start using Low Vision Rehabilitation to help our patients perform their required activities of daily living

7 Daily Living Activities Do we think about the way visually impaired patients perform the following activities of daily living: financial management bill paying reading menus seeing tapes, CD s identifying money mailing envelopes writing checks Thermometers seeing clothing labels remote controls

8 Activities of Daily Living seeing thermostats setting appliance dials seeing television dials pressing elevator buttons playing games (e.g., bingo, cards, etc.) addressing envelopes seeing street/store signs making a shopping list self-care: grooming, eating, dressing housecleaning: ironing, dusting, taking correct meds

9 Consequences All this leads to: Confusion, Frustration, Avoidance, Isolation, Fear, Depression, etc.

10 Low Vision Coding At the current time, Medicare does not reimburse for low vision examinations. If the purpose of an office visit is strictly for low vision, the service may not be reimbursed by any insurance company. If the purpose for the visit, is to see if the person may benefit from low vision rehabilitation, appropriate CPT/ICDA codes may be used.

11 MEDICARE and Other Health Care Plans: What Do They Cover? Medicare pays for the diagnosis and treatment of sickness and illness necessitated by a patient symptom. The office visit may also be physician directed. The same is typically true for other health care insurance carriers. Patient symptoms pertaining to visual impairments should be clearly documented as part of your patient's case history.

12 Chief Complaint The chief complaint is a concise statement describing the symptoms, problems, conditions, diagnosis, physician recommended return, or other factors that are the reason for the encounter, usually in the patient's own words.

13 The Chief Complaint - The Medicare Carrier s Manual, Part 3 Section 2320 reads: The coverage of services rendered by a physician is dependent on the purpose of the examination rather than the ultimate diagnosis of the patient's condition When a beneficiary goes to a physician with a complaint or symptom of an eye disease or injury, the services (except refractions) are covered regardless of the fact that only eyeglasses may have been prescribed When a beneficiary goes for an eye examination with no specific complaint, the expenses are not covered even though as a result of such examination the doctor discovered a pathologic condition!

14 Fraud and Abuse With health care fraud and abuse issues on the rise, it is imperative that each practitioner clearly understands all the ramifications of billing third party carriers When you use a CPT code, your record must be able to support the code!

15 Key Questions for You to Consider? Do your records support the codes you ve billed? > Relates to both office visits and procedures > Relates to patient symptoms reported in the case history and findings by the clinician If yes there is nothing to worry about If you bill based upon what sounds right or what reimburses higher, you may be in trouble.

16 Fundamentals of an Office Visit What will you do? > Clinical guidelines > Evidence based medicine What does the patient need? > May not be what you want to do What is in the patient s best interest?

17 Billing Pearls: All patients should be billed in a similar manner regardless of insurance coverage. Problems relating to low vision should NOT be billed to insurance carriers for ONLY those patients who have health insurance.

18 Considerations Case History: Medicare s policy clearly indicates that they pay for the REASON the patient is in your office and not for what you might find. In order to bill Medicare (and other carriers) for any examination, you must document a Chief Complaint or a patient symptom. A chief complaint could also be physician directed such as you asked me to return to check my diabetes.

19 CPT and ICD-9 Eyecare practitioners should be thoroughly familiar with the definitions of office visits it CPT-4 coding. Optometrists should be able to utilize either the E&M office visit codes (99000) or the Ophthalmologic Eye Codes (92000). In addition, you will need to be thoroughly familiar with the ICDA codes that are pertinent to the diagnosis and treatment of low vision including the visual impairment codes.

20 99000 vs When a patient obtains a low vision exam, many practitioners view this visit as a time to evaluate and determine whether low vision devices and/or visual rehabilitation will improve the patient s functional visual skills. Specific goals are set and solutions are investigated These visits may be better coded with than as these encounters typically require more patient counseling and education

21 92000 vs Requirements for codes are more general than those for the codes > require history and a chief complaint > series requires considerable more documentation, particularly in certain levels of history of present illness, review of systems and past/family/social history

22 92000 Codes Can be used to report both > Medical eye care visits > Routine eye care > Many insurance carrier are considering the codes to be E&M codes for purposes of medical review and audit Refraction is a separate service (92015) and is not included in any other code, unless required by contract with payer (NYS Medicaid)

23 Requirements of Intermediate Ophthalmological Service 92002/92012 Payers may develop their own interpretations of these definitions BUT the following elements are included in the CPT definition: > A new or existing condition > Complicated with a new diagnostic or management problem not necessarily relating to the primary diagnosis > History > General medical observation > External ocular/adnexal examination > Other diagnostic procedures as indicated > Initiation or continuation of a diagnostic and treatment program > 1 To 7 (or 8) examination elements (Carrier Specific)

24 Requirements of Intermediate Ophthalmological Service 92002/92012 > Does this mean that if one (or more) of these elements is missing, the visit cannot be coded as an intermediate ophthalmological service? You bet it does!

25 What is General Medical Evaluation? Poorly defined Probably includes: > Comments on how the patient is doing > Are there changes in visual functioning > Is the person groomed appropriately > Can he/she walk independently > Does he/she appear well nourished

26 Comprehensive Exams /92014 Comprehensive ophthalmological services describes a general evaluation of the complete visual system. The comprehensive services constitute a single service entity but need not be performed at one session. The service includes history, general medical observation, external and ophthalmoscopic examinations, gross visual fields and basic sensorimotor examination. It often includes, as indicated: biomicroscopy, examination with cycloplegia or mydriasis and tonometry. It always includes initiation of diagnostic and treatment programs.

27 Requirements of Comprehensive Ophthalmological Service 92004/92014 Payers may develop their own interpretations of this definition The elements that are required by the CPT definition are: 1. General evaluation of the complete visual system 2. History 3. General medical observation 4. External examination 5. Ophthalmoscopic examination (with or without cycloplegia or mydriasis 6. Gross visual fields 7. Basic sensorimotor examination 8. Initiation of diagnostic and treatment program 9. Greater than 8 examination elements (carrier specific)

28 Requirements Elements for a Comprehensive Ophthalmological Service > Does this mean that if one (or more) of these elements is missing, the visit cannot be coded as comprehensive ophthalmological service? You bet it does!

29 92000 Codes Rigid definitions Carrier frequently number of visits allowed in a specified time All four levels of examination require initiation or continuation of diagnostic and treatment programs

30 Initiation or Continuation of Diagnostic and Treatment Services Includes the following: > NY Local Policy:» The prescription of medications» Lenses & other therapy» And arranging for special ophthalmological, diagnostic or treatment services, consultation, laboratory and radiological studies as may be indicated > CPT-4 Prescription of medication, and arranging for special ophthalmological diagnostic or treatment services, consultations, laboratory services and radiological services

31 Initiating a Diagnostic and Treatment Plan Communication with patient Complete the medical record Set-up a follow-up date > For recheck > For additional tests Prescribing medications (OTC s and prescribed) Contact lens and spectacle prescriptions Referring out for second opinions Etc., etc., etc.,

32 99000 Codes Visit codes are chosen based upon the details of the definitions in CPT and the Documentation Guidelines for three key components: > Case History > Physical Examination > Medical Decision Making

33 Grading the Office Visit New Patient Level Code History Exam Medical Decision Problem Focused Problem Focused Expanded PF Expande d PF Straight Forward Straight Forward Time (Minutes) Detailed Detailed Low Comprehensive Comp Moderat 40 e Comprehensive Comp High 50 New Patient visit is graded to the lowest of the three components: History, Exam, Medical Decision Making All 3 are required 10 20

34 Example of Code History Exam Medical Decision Problem Focused Problem Focused Expanded PF Expanded PF Straight Forward Straight Forward Time (Minutes) Detailed Detailed Low Comprehensive Comp Moderate Comprehensive Comp High

35 Documentation Guidelines Detailed history > Extended history of present illness (4-8 elements) > Extended review of systems (at least 2 systems reviewed) > Problem pertinent past/family/social history (1 area) Detailed physical examination > At least nine examination elements recorded Low complexity medical decision making > Limited diagnoses/management options Low risk

36 How Do We Use Current Coding Systems for our Low Vision Patients?

37 Chief Complaint Every record requires a chief complaint If you are billing for low vision related problems, the chief complaint should relate to the final diagnosis or diagnoses as well as patient symptoms that are medical in nature

38 Chief Complaint Examples I would like a second opinion regarding my diabetic retinopathy I have macular degeneration and I can no longer read, write, or see my medications I have retinitis pigmentosa and feel my vision has deteriorated I need guidance in dealing with cataracts Patient has decreased visual acuity/constricted visual fields Am I a candidate for LOW VISION REHABILITATION?

39 Chief Complaint If the chief complaint is low vision related (i.e., I want a low vision exam), you may have not pass an audit.

40 Chief Complaint Are these appropriate? > I m here for a low vision exam > I m heard you re the only person who can help me with magnifiers > Dr. Retina Referred me to you for a low vision examination Probably NOT

41 Chief Complaint The chief complaint will help determine if the coverage is Medical or Optical Make sure the patient signs a statement that he is responsible for non-covered services if you consider a low vision examination to be a non-covered service.

42 What's An ABN? An Advance Beneficiary Notice (ABN) is a standardized form (CMS-R-131-G) that notifies a beneficiary in writing before a procedure why Medicare is unlikely to cover it. The provider must describe the procedure in simple language and explain why it will not be covered by Medicare Bill procedures with GA modifier Not required for a refraction

43 Billing Pearls Avoid using standardized billing practices such as a person with symptoms of macular degeneration is always an E&M level 3 or 4. Only the doctor should assign the code and not his/her office staff.

44 History The history portion of E&M Coding is a key area regarding the signs and symptoms of symptoms relating to conditions that can cause low vision. History includes 4 basic elements:» Chief Complaint, History of Present Illness, Review of Systems, and Family and/or Social History

45 History of Present Illness History of Present Illness is an area where many questions directly relating to problems causing a person to have low vision can be asked

46 History of Present Illness 7 Components Location: > right eye, left eye, both eyes, forehead, neck, shoulder, lid, side of head, etc.. Quality: > itch, burn, dry, scratchy, blur, decreased vision, haze, fuzz, double, puffy, red, sticky, swollen, ache, tearing, floaters, glare, haze, distorted, halo, crossed, spots, droopy lid, pain, discomfort, loss of vision,etc.

47 History of Present Illness: Severity: > stable, moderate, sharp, dull, a little, a lot, intense, disabling, extreme, poor, some Timing: > all the time, suddenly, once in a while, constant, AM, PM, yesterday, comes, goes

48 History of Present Illness: Context: > at work, while reading, while driving, in bright lights, at computer, looking up/down, looking to the right/left Duration: > minutes,hours,days,weeks,months,years,always,once, twice, occasionally

49 History of Present Illness: Modifying factors: > hobbies, medication, sleeping, allergy, trauma, surgery, systemic diseases, previous injuries, pains, medications, treatment, Associated signs: > headaches, cloudy, puffy, redness, swelling, pain, twitch, dizzy, vomiting, nauseous, pressure, bleeding, hot/cold, discharge

50 Examination The examination portion should relate to the problems of low vision problem. Four (4) levels of exams: > problem focused > expanded problem focused > detailed, and > comprehensive Check you CPT books and local insurance carriers for specific definitions

51 Level of Medical Decision Making Probably the hardest area to quantify Four (4) levels: 1. straightforward; 2. low complexity; 3. moderate complexity; and 4. high complexity Appropriate level is chosen according to the complexity of establishing the diagnosis and/or choosing the treatment.

52 Level of Medical Decision Making Treatment options for patients with low vision may include: > referral back to another health care providers > a recommendation to return back to your office for additional testing and possible low vision devices > prescription of low vision devices (non-covered)

53 92000 vs If the doctor chooses to utilize the codes instead of the 99000, he/she should check with the specific requirements required by insurance carriers. > codes require the initiation of diagnostic and treatment services > require a dilation (unless contraindicated)

54 Prolonged Services CPT Prolonged service in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour List separately in addition to code for office or other outpatient Evaluation and Management service) > Use in conjunction with , , , , 90809,90815) each additional 30 minutes (List separately in addition to code for prolonged service) Average reimbursement is $95 depending upon your region The Medicare manual says you must record the start and end times of the visit in the medical record Only provider time counts, not staff time CPT 2012 removed reference to face to face and added direct patient contact

55 Prolonged Services Code can be used for seriously ill patients; this code is used once per day Example: > If you are spending over 40-minutes with a patient and have all of the criteria, you are going to document and file a > However, if you end up spending any additional time, for example, over another 30-minutes with the patient, and your face-to-face total time counting all other services is 75- minutes, you can code the additional time with CPT code

56 Prolonged Services Prolonged services of less than 30-minutes total duration on a given date is not separately reported because the work involved in included in the total work of the E & M codes CPT codes may be used to report each additional 30- minutes beyond the first hour of prolonged service Example: > A physician performed a visit that meets and the total duration of direct patient care (including the visit) was 65-minutes. The physician bills code and one unit of > A physician performed a visit that meets and the total duration of direct patient care was 35-minutes. The physician cannot bill prolonged services because the duration of face-to-face did not meet the threshold time for billing prolonged services.

57 Prolonged Service Codes Has to be Direct Patient Care time with the Provider CPT Code Typical Time Threshold to Bill 99354* Threshold to Bill ** * is billed only once ** can be billed multiple times in 30-minute increments

58 Prolonged Services Total Duration of Prolonged Services Less than 30-minutes minutes (30-minutes to 1 hour and 14-minutes) minutes (1 hour 15-minutes to 1 hour and 44-minutes 105 or more (1 hour 45-minutes or more) Codes Not Reported Separately x x x x x 2 (or more each additional 30-minutes)

59 Specialized Codes If MEDICALLY NECESSARY, practitioners may wish to consider the following specialized CPT-4 Procedures: > Extended Ophthalmoscopy /92226 > Visual Fields > OCT 92133; These codes require an "Interpretation and Report

60 Specialized Codes Ocular Photography Each practitioner should review the Medicare Policies in place and the requirements for utilizing these codes which are being scrutinized (especially 92225/92226 and 92133/92134 OCT) Visual Fields Separate Procedure > Check LCD for the patient s diagnosis > NY One VF for a patient with Macular Degeneration > Only Confrontation VF part of 92000/99000

61 Practitioner Decision Do you want to consider the examination for a patient with low vision to be partially covered or totally noncovered?

62 The Low Vision Exam is a Non-Covered Service If the practitioner wishes to consider the office visit to be completely non-covered, then he/she should list the chief complaint as a low vision exam or I m here for low vision devices. Have the patient sign a non-covered service waiver and bill the patient your low vision exam fee. Carefully explain to the patient that this is a NON-COVERED Service. Bill with the GA Modifier

63 The Low Vision Exam is a Covered Service The practitioner should considering splitting his/her exam fee into a covered portion and a non-covered portion: > Covered Portion: Case History, Exam, MDM - THE MEDICAL EYE PORTION and the > Non-Covered Portion: Refraction and Low Vision Examination

64 The Low Vision Exam is a Covered Service The Practitioner should set a fee for each of these components and bill all patients in a similar manner regardless of the patient s insurance coverage. The appropriate Medical Portion of the Exam is billed to the Medical Health Plan (patient is responsible for copays and deductibles)

65 The Low Vision Exam is a Covered Service The patient pays for the refraction and the low vision portion of the examination

66 Refraction A specialized ophthalmological procedure - CPT which is a non-covered service by CMS definition Low VISION Refraction - no specialized CPT codes > Single Level vs. Multiple Levels

67 Refraction Each practitioner may wish to consider setting multiple refractive fees > Level 1 - Simple Refraction > Level 2 - Simple Low Vision Refraction - e.g. Low Vision Patient > Level 3 - Complex Low Vision Refraction - e.g. Legally Blind Patient

68 Refraction Can you change different fees for the refraction? If you are concerned about this, consider using modifiers > Modifier 22

69 Example Date CPT Total Fee Billed to Insurance Carrier Patient Responsibility $150 $130 $20 (Co-pay) $ $100 $80 $ $50 0 $50 (LV Device) Total $400 $210 $190

70 ICD 9 Diagnosis Codes: Use the exact code for each diagnosis (four or five digits The first diagnosis code you list should be the chief complaint that brought the patient in Be as specific as you can - Avoid Unspecified Codes Code the patient s condition to the highest degree of certainty for the appointment. Add the Vision Impairment Codes

71 ICD-9 Codes For Vision Impairment That Support Medical Necessity for Rehab Be = better eye Le= lesser eye SCOTOMA central area Generalized contraction or constriction Homonymous bilateral field defects Heteronymous bilateral field defects Be - total impairment Le - total impairment Be - near-total impairment; Le- total impairment Be - moderate impairment Le - profound impairment Be - severe impairment Le - severe impairment Be - moderate impairment Le - severe impairment Be - moderate impairment Le - moderate impairment

72 ICD-9 Codes For Vision Impairment That Support Medical Necessity for Rehab Be - near-total impairment Le - near-total impairment Be - profound impairment Le - total impairment Be - profound impairment Le - near-total impairment Be - profound impairment Le - profound impairment Be - severe impairment Le - total impairment Be - severe impairment Le - near-total impairment Be - severe impairment Le - profound Be - moderate Le - total impairment Be - moderate impairment Le near-total

73 The Concept of Time Time can be utilized to increase the level of E&M coding when you spend more than 50% of the office time coordinating and counseling you patient. It is critical that you document the time you started the exam as well as the you completed the exam Time needs to be documented Time is face-to-face

74 The Concept of Time Concepts of counseling low patient is extremely apropos for the low vision patient Again this counseling should be directly related to a medical office visit such as the prognosis of macular degeneration or the removal of a cataract in a legally blind person. It should not be used when teaching a patient to use a stand magnifier.

75 Coding Claims Based on Time When counseling and/or coordination of care dominates (more than 50%) of the encounter, time may be considered the key or controlling factor for a particular level of service In this case, the provider may be an appropriate level of service based on the TOTAL ENCOUNTER TIME You should record counseling topics and/or how time was spent coordinating the patient s care

76 The Concept of Time Record encounter start and stop time Record refraction time Record Counseling/Coordinating Time E & M Time = Total Encounter Time refraction time other procedure time

77 Selecting a Code Use the time listed in CPT (this is the typical time a physicians spends with the patient and or the family) If the time spent engaged in counseling and/or coordination of care is more than 50% of the typical time listed, then a code can be chosen and billed

78 Example Example 1 > Face-to-Face Time 25 minutes (CPT -4) > Total Counseling Time 15 minutes > Level of Care (Typical Time 25 minutes) (Time is key factor as opposed to History,Exam & MDM) Example 2 > Face-to-Face Time 60 minutes > Total Counseling Time 30 minutes > Level of Care Base on history, exam, and MDM (50% not exceeded)

79 Coordinating Care Again, this may be perfect fully suitable for a low vision patient

80 99211 Patient educational component involved during the dispensing of low vision devices Tech time

81 Consultation DON T Forget the 5 R s 1. REASON; 2. REQUEST; 3. REVIEW and RENDER OPINION; 4. RECOMMENDATION; and 5. REPORT, RETURN PATIENT

82 Consultation vs. Referral Patient presents with suspect problem or condition with an undetermined cause of treatment for the purpose of obtaining advice or opinion for care Patient with a known problem or condition with a prescribed or known course of treatment sent with the intent of treatment or management of patient care total or partial

83 Consultation vs. Referral Patient is instructed to followup with the primary or attending physician A written report of findings and suggestions is required and sent to the requesting physician. Patient is scheduled for a return appointment for treatment or to discuss test results No written report is required. A report is sent as a courtesy detailing the care or progress.

84 Critical Coding Concepts to Consider Establishing Medical Necessity New vs. Established Chief complaint Medical vs. Refractive Contractual obligations for Vision Care Plans Supplemental Testing > medical necessity

85 Other Considerations Low Vision Exam/Rehabilitation > One visit or multiple visits Vision Care Plans > Can Reimburse up to $1,000 > Pre-Certification usually required

86 Vision Rehabilitation: A further way we can help our low vision patients! (Without Banging our Heads!) There is a nationwide trend to consider low vision rehabilitation in a similar way to other physical rehabilitation modalities such as OT, PT, and Speech Therapy.

87 Concern - Problem It s extremely confusing and frustrating for a visually impaired patient to assess the system for help and then determine that low vision services may not be reimbursed under Medicare! But now Rehab is covered!

88 And the Next Key Question is? Does Medicare Cover Vision Rehabilitation? And the answer is..

89 YES! However, we must do the following: > Define Visual Rehabilitation, and > Follow the Rehabilitation Model of Rendering Care which includes accurate and detailed office records and notes as well as achieving specific goals

90 Why this topic??? Eyecare providers have the resources and the knowledge to manage patients with vision impairment Only 2% of people with vision impairment receive vision rehabilitation services Although Medicare does not pay for low vision exams and devices, it does NOW, in most states, reimburse for Vision Rehabilitation Even though this is a new trend, there are still a limited number of practitioners managing low vision patients

91 Origin of Low Vision Rehabilitation The concept of vision rehabilitation was first developed in the late 1940 s when WW II veterans with eye injuries needed help returning to the work force. Optometrists and MDs led the effort to develop devices and techniques that could make young veterans employable, and the Veterans Administration hospitals still offer vision rehabilitation services such as Blind Rehabilitation and VICTORS

92 Statistics It is estimated that there are 13.5 million visually impaired persons over the age 45 in US. The number of Americans over the age 65 will more than double over the next 50 years, from 33.2 million in 1994 to 80 million in Because the most frequent causes of low vision are age related, the aging trend can be expected to increase the number of visually impaired adults substantially. Of the four million Americans with low vision, 70% (2.9 million) are good rehabilitation candidates, yet only 1 to 2% are involved in rehabilitation.

93 Statistics Low vision is the third most commonly occurring physical impairment in those over 65, exceeded only by heart disease and arthritis. There is a close relationship between vision, balance and musculoskeletal systems/ of those low vision patients surveyed 31% reported they had fallen last year. 80% of processed information comes from vision Costs for medical and long term care for older Americans who lose their independence each year are $26 billion greater than if they had remained independent that year.

94 Trends The vast majority of visually impaired and blind people are over age 65 Most visual impairment and blindness are caused by age-related eye diseases As the population ages over the next 25 years, the number of older visually impaired and blind people in this country will double

95 Trends The major cause of what reduces independence is not cancer or heart attacks, but rather conditions such as visual loss, memory and physical loss and incontinence

96 As a Result There is a nationwide trend to consider low vision rehabilitation in a similar way to other physical rehabilitation modalities such as OT, PT, and Speech Therapy.

97 But There are Still Problems/Concerns Many eyecare practitioners tell their patients that nothing more can be done to improve the functional vision that their patients still have. Medicare does not pay for low vision examinations and devices HOWEVER There is now a national Medicare policy on low vision rehabilitation and an approved LCD in many states in the country!

98 However We must not think as Low Vision as the fitting and prescribing of Low Vision Devices but rather as a form of Rehabilitation where we teach and train people to improve functional skills which are needed for ADL s (Activities of Daily Living) Low Vision is not just magnifiers. It is looking at human beings & trying to help them meet their goals Sarah Appel, OD

99 VA and ADL To write a check - 20/90 To groom one s self - 20/100

100 VA and ADL To watch TV at 10 feet - 20/100 To sew a hem - 20/50

101 Daily Living Activities Do we think about the way visually impaired patients perform the following check list activities of daily living? > Financial management including paying bills and identifying money; writing a shopping list > Seeing street signs > Reading menus; setting thermostats > Seeing tapes & CD s; playing games (Bingo) > Writing checks and mailing envelopes > Seeing thermometers and remote controls > Seeing clothing labels; setting dials (TV) > Housecleaning: ironing, dusting, etc.. > Taking the correct medications & self care

102 Activities of Daily Living Mobility: > efficient use of vision > adaptation to glare and changes in lighting > identification of low contrast targets: curbs > analyzing traffic flow > avoiding obstacles > public transportation Shopping: > locating products > finding the correct aisle & the cashier Reading: > books, mail, flyers > bills and cash receipts

103 Consequences All this leads to: Confusion, Frustration, Avoidance, Isolation, Fear, Depression, etc..

104 End Result Altered Quality of Life

105 Let s Talk Rehabilitation There is a nationwide trend to consider low vision rehabilitation in a similar way to other physical rehabilitation modalities such as OT, PT, and Speech Therapy. The time to talk about this is NOW!

106 World Health Organization Terminology for Impairment and Disability Parallels with Other Types of Rehabilitation

107 Impairment/Disability Disorder An anatomical deviation from normal (can be congenital or acquired) it s a diagnosis > example: cataract, age-related macular degeneration; glaucoma; diabetic retinopathy Impairment Disorders can lead to impairments which now defined as abnormalities in visual functioning. They are classified by performance on visual function tests such as example: > VA loss, Field loss; Reduced Contrast > (can be physiological or psychological; acquired or heredity)

108 Disability/Handicap Visual Disabilities: Visual impairments lead to vision disabilities as defined as limitations imposed by visual impairments on a person s ability to perform activities that are important to the person. The goal of rehabilitation is to restore function by enhancing impaired vision and teaching the patient how to compensate for the disabling effects of the visual impairment. It s a restriction/inability to perform tasks in a manner considered normal. > example: inability to read, drive, groom, etc.. Handicap: A disadvantage that prevents or limits fulfillment of a role that the individual would consider normal > example: patient cannot work, socialize or perform hobbies

109 Defining Vision Rehabilitation Vision rehabilitation is the evaluation & management of functional vision loss using rehabilitation interventions which reduce deficits in performance of ADL s while enhancing quality of life

110 Defining Vision Rehabilitation Vision rehabilitation is the process of treatment that helps visually disabled individuals to attain maximum function, a sense of well-being, and a personally satisfying level of independence. Functioning can be maximized by therapy to improve visual abilities, through the use of optical, non-optical, or electro-optical devices or by teaching compensatory non-visual approaches. Vision rehabilitation may be necessitated by any condition, disease, or injury that cause a visual impairment serious enough to result in functional limitations or disability. Vision rehabilitation may include, but is not limited to, medical, optometric, allied health, social, educational, and psychological services. > Adapted from the definition of rehabilitation in Taber s Medical Dictionary

111 What is Vision Rehabilitation? It is the evaluation and treatment of individuals with low vision to help them overcome the handicapping effect of their visual impairment It is maximizing a patient s remaining functional vision along with medical services and psychological counseling to cope with vision impairment It is teaching a patient how to restructure all their activities to compensate for low vision and provide practical adaptations for activities of daily living It is reducing the functional impact of the vision loss on people s lives so that they can maintain independence, productive activity and life satisfaction

112 Goals of Physical Medicine: Prevent injury Minimize pathology Prevent secondary complications Enhance function of involved systems Develop compensatory strategies

113 Goals of Vision Rehabilitation Training visually impaired patients to travel more safely thereby preventing injury Improving patients visual function enabling them to maintain better health (seeing their food, taking the correct medications) Reduce the complications of isolation, loneliness and depression Visual function may be enhanced by visual skills training, as well optical and non-optical devices, filters, etc.. To maximize independence, patients need to be taught compensatory skills such as orientation and mobility, adaptations of their homes, and techniques to perform activities of daily living

114 Goals of Physical Medicine vs. Low Vision Rehabilitation The Goals are Similar if Not the Same! Physical Therapy Prevent injury Minimize pathology Prevent Secondary Complications LV Rehabilitation Prevent injury with safe travel Minimize pathology teach visually impaired diabetics to inject insulin Prevent isolation & depression

115 Indications of Coverage Coverage of low vision rehabilitative services are considered reasonable and necessary only for patients who have the following: > A moderate of severe visual impairment, not correctable by conventional refractive means > A functional impairment, associated with the visual deficit, such as independent daily living activities > Patients with a clear potential for significant improvement in function over a reasonable period of time

116 Vision Rehabilitation A comprehensive team approach involving: > ophthalmology, optometry, OT, PT, social work, teachers of the visually impaired, blind rehab therapists, etc. A team approach The significantly negative impact of visual impairment on the well-being and the quality of life of individuals of all ages can, in many cases be lessened by appropriate low vision intervention and vision rehabilitation.

117 Are we rehabilitating vision or rather a person with a visual loss? The purpose of rehabilitative therapy is to maximize a patient s use of his/her residual vision To provide patients with many practical adaptations for activities of daily living which can lead to an increased level of functional ability & independence Low vision rehabilitative therapy utilizes aids and education to minimize vision-related disability when no restorative program (e.g. Correction of refractive error or cataract surgery) is possible Rehabilitation appears to be more effective if it is started as soon as functional visual difficulties are identified

118 Level of Visual Impairment Most Medicare LMRP s (now called LCD s) discuss 2 levels of impairment although several exist: > Moderate visual impairment > Severe visual impairment These disabilities can, limit both personal and socioeconomic independence and lead to isolation and depression. Loss of independence and the ability to enjoy leisure activities are predominant concerns of the visually impaired population

119 Definition of Levels of Vision Impairment Five Levels Exist: > Moderate Visual impairment= best corrected visual acuity is less than 20/60 in the better eye (including 20/70 to 20/160) > Severe Visual Impairment (legal blindness) = best CORRCTED visual acuity is less than 20/160 including 20/200 to 20/400, or visual field is 20 degrees or less > Profound Visual Impairment (moderate blindness) = best corrected visual acuity is less than 20/140 or visual field is 10 degrees or less in the better eye (Goldmann isopter III 4E. 1/100 white test object) > Near-total Visual impairment (severe blindness) = best corrected visual acuity is less than 20/1000, or visual field is 5 degrees or less > Total Visual impairment = no light perception (total blindness)

120 Vision Rehabilitation Follows the Same Model as other forms of Rehabilitation Get a copy of New York (or your state s) LCD on Vision Rehabilitation it s an excellent resource you cannot do without!. Check it periodically for updates: ngsmedicare.com Vision rehabilitation should be considered in similar way to other physical rehabilitation modalities such as OT, PT, and speech therapy. Therefore let s follow a similar model of rendering care as well as billing.

121 Vision Rehabilitation Medical Mode Low Vision Evaluation by Physician (O.D. or M.D.) Rehabilitation Services (OT, PT, Physicians) > Low Vision Therapists, Orientation and Mobility Specialists, etc. > Not licensed

122 Policy Guidelines CMS National Policy > Program guideline from 2002 LCD Local Coverage Determinations State Laws > Individual Practice Acts > State Board Approvals

123 Rehabilitation Model Initial Visit Insult: CVA, TBI or Trauma. Emergency Care Medical Care Until Stable Referral to Physiatrist for Eval. Will the patient benefit from rehab? Referral to OT, PT for Eval. OT/PT evaluation codes Therapy Initial Visit to OD/MD for eye diseases (confirm diagnosis, treat, Emergency Eye Care, etc.. F/U until diagnosis is confirmed and condition is stable. Low vision Eval. Will the patient benefit from LV devices and/or rehab? Impaired Compensation Evaluation Will the patient benefit from LV Rehab? Therapy

124 Rehabilitation Model Initial Visit Insult: CVA TBI, Trauma Emergency Care Initially (Exams & Procedures) Medical Care Until Stable (Exams & Procedures) Referral to Physiatrist for Eval Will patient benefit from rehab? (Exams & Procedures) Referral to OT, PT for Evaluation (Can the Person be helped?) OT/ PT Evaluation Codes or Therapy Rehab Codes 97535, etc. Initial Visit to OD/MD for Eye Diseases (Exams & Procedures) Follow-up until Dx is confirmed or patient is stable (Exams & Procedures) Low Vision Evaluation 92000/99000 & Refraction Will patient benefit from LV devices/rehab? Impaired Compensation Evaluation We do not have unique codes or Therapy Rehab Codes 97535, etc.

125 Low Vision Rehabilitation Low Vision Examination (O.D. or M.D.) > Determination of diagnosis and level of visual impairment > Treatment options Impaired Compensation Visit: > Qualifying criteria (e.g. VFQ 25, Visual Efficiency, etc.) > Establish attainable treatment goals for rehabilitation > Develop an Individual Rehabilitation Plan (IRP) Physician: > Confirms the disease process causing the impairment, determines the impairment level, determines the disability, considers treatment, performs low vision evaluation, writes the IRP

126 Will The Patient Benefit From Low Vision Rehabilitation? Patients must have a clear potential for significant improvement in function following rehabilitation in a reasonable period of time. If the patient lives confidently with their current visual function, visual rehabilitation may not be medically necessary. Vision impairment ranging from low vision to total blindness may result from a primary eye diagnosis, such as macular degeneration, retinitis pigmentosa, glaucoma, or as a condition secondary to another primary diagnosis such as diabetes or AIDS.

127 Will Your Patients Benefit From a Low Vision Program? Ask the Right Questions! > are you having difficulty with coordination? - e.g. grasping objects, using utensils > are you having difficulty with homemaking activities? - cooking, shopping, etc. > are you having difficulty with grooming, dressing, make-up, shaving, bathing? > are you having difficulty reading? > can you see your pills, eye drops?

128 Will Your Patients Benefit From a Vision Rehabilitation Program? ASK THE RIGHT QUESTIONS! > do you have magnifying devices and can you use them to perform your daily activities? > are you having trouble with activities of daily living? > have you received proper training with your magnifying devices? > are you having trouble walking or getting around; have you fallen lately? > have you given up hobbies (knitting, sewing)?

129 Visual Rehabilitation A Quick Overview Examine the patient to determine if they will benefit from Vision Rehabilitation Determine if you will do the rehabilitation in your office or will you refer the patient out for rehab training If you do the training: > Establish the treatment Plan (Impaired Compensation Visit) > Perform the therapy and keep detailed notes > Assess progress (if needed) at appropriate intervals > When therapy is complete, fill out a discharge summary If you refer the patient out, coordinate care and re-assess goals every 4 weeks (minimum) until rehab is complete

130 Documentation Requirements Once coverage criteria for low vision rehabilitation have been identified, an individualized plan of care must be entered into the patient s record. A plan of care includes rehabilitation goals, progress assessment at each session and determination of discharge. Minimum documentation requirements in the plan of care and sessions executing the plan are as follows; 1. Specific goals based upon answers the patient has provided to questions about survival tasks, communication tasks, and mobility concerns; for example to increase reading speed to 100 words per minute and angular size of text from 20 to 70 minutes of arc. 2. A description of the method, which will be employed to achieve each goal, should be in the treatment plan. Examples include (1) a patient with 6/20 vision that wants to read 1 (one) M, normal text print. Scotoma awareness and fixation stability will be addressed and the effectiveness of a 3.5 x magnifier will be assessed

131 Documentation Requirements (continued) 3. Quantitative measurements of baseline performance should be compared to current performance measurements at each session and clearly documented. A treatment plan may call for achieving goals in a sequential manner. Therefore, quantitative performance measurements of only the goals currently being addressed would be appropriate. For example, if the patient has already mastered the use of a magnifier to spot read standard print labels, but wishes to read continuous print, requiring strategies for scanning, fixation stability, and line finding, then current compared to baseline reading speed would be an appropriate quantitative measure of progress. The size of print, which could be read, would not be necessary to record because it had previously been addressed. 4. Sufficient time between visits is necessary for the patient to apply low vision training to their activities of daily living. Following practice by the patient with techniques to minimize disability the low vision specialist can assess the patient's improvement.

132 Documentation Requirements (continued) 5. The medical necessity for LVR ends when the patient demonstrates no progress after a reasonable number of documented attempts by the therapist to assist the patient and/or modify the care plan. The patient's improvement, or lack thereof, can be measured with quantitative measurements Subsequent treatment for goals that have been met or are determined to be unattainable will be considered maintenance and are a noncovered benefit. Furthermore, as measurements plateau, the patient's services for that particular service should be terminated. 6. Each session's progress report should identify changes in rehabilitation goals, therapy schedules, or treatment plan. 7. Each session using time dependent codes, either therapeutic procedures or prolonged services, must have the face-to-face time documented to the minute. 8. A the completion of therapy, a discharge summary shall be included in the chart stating the level of progress at discharge.

133 Initial Visit to Optometrist: Initial E & M Visit (99000 code) or Appropriate (Medical) initial diagnosis, confirm diagnosis, treatment if needed, refer out if needed, follow-up until patient is stable and ready for rehabilitation Low Vision Examination (includes refraction) Appropriate Special Procedures: VF, Extended Ophthalmoscopy, etc.

134 Specific State Requirements When a comprehensive low vision evaluation by a physician that confirms and delineates functional deficits compromising daily activities is not available, a score of 70 on the Vision Function Questionnaire (VFQ) is required for rehabilitation. VFQ asks questions such as: > Can you apply make-up or shave > Can you identify denominations of money or sign a check?

135 Therapy Evaluation Visit Impaired Compensation Evaluation Goal of this Visit: > To Access the Rehabilitee s Potential» Use E & M or s (We do not have our own unique code/codes for this as of yet) And to write THE TREATMENT PLAN this includes a determination if the following are needed and appropriate:» OT/PT Evaluation (if requested by OD/MD)» O & M Evaluation» Social Worker/Psychosocial Evaluation

136 What s Done in the Impaired Compensation Visit a) Detailed Case History focuses on presenting problems of the patient (i.e. their limitations). It highlights the patient s limitations to perform necessary or valued activities. It begins to define the foundations upon which rehabilitation builds solutions to the presenting problems. > It clearly identifies those ADL s the patient is having difficulty with!

137 What s Done in this Visit (Con t): b) Functional Examination:» 1) 12 Components of the Eye» 2) Visual Impairments: - Visual Acuity - Contrast sensitivity - Binocular Vision - Confrontation Fields - Glare Assessment

138 What s Done in this Visit (Con t)»3) Visual Performance Testing Reading Writing Face and object Identification Mobility»4) Orientation to time, place, etc.»5) Assessment of Mood c) Writing the Treatment Plan

139 Therapy Compensation Visit: Name of Patient: DOB: Date of Exam: Referred by: Ocular Disease Causing Visual Impairment: Past Medical History: Past Surgical History: Allergies: Social History: Who do you live with? Lives Alone _ Married & lives with spouse Live with Children Other: Are you able to take care of yourself? What was the last grade you completed in school? Do you smoke or drink? Work history: Currently Working Looking for Work Homemaker Other: Home Environment: Adaptive Equipment Used: Concerns about mobility including recent falls:

140 Therapy Compensation Visit Visual Processing deficits noted: Depth Perception Difficulties Visual-Motor Coordination Figure Ground Pattern Recognition None Concerns about near vision: Illumination Used: Vocations/Hobbies: Hearing Difficulties: Current Reading Ability: Uses Tape Recorder Knows About Talking Books Primary Goal: Additional Goals:

141 Impaired Compensation Visit (Con t) VISUAL FINDINGS: Acuity: OD OS OU Distance ( ) Near ( ) Visual Fields: Contrast Sensitivity: Tracking and Scanning: Photosensitivity/Glare Current Optical Devices: Previous OT/PT Cognitive Status: Orientation to time and place Attention Safety and judgment Memory Awareness Following Instructions

142 Impaired Compensation Visit (Con t) - Difficulty with ADL s Telling Time on Watch Clock Money Management Community Skills Medication Management Dressing Grooming/Hygiene Mobility:» Do you get around outdoors» Loss of Balance» Climbing Stairs» Use of Transportation (Elevator, Train, Car) - Street Crossings - Negotiation Close Spaces - Can you function at home? - Do you drive? - Do you use a cane?

143 Difficulty with ADL s (Con t) Reading: > Do you read print? > Can you read:» Newspaper Headlines» Large Print» Textbooks» Newspaper» Magazines» Telephone Book» Your mail» Your bills» Price Tags» Medication bottles» Recipes» Other: How much reading do you do? What kind of light do you use for reading? Do you want to read?

144 Difficulty with ADL s (Con t) Writing: > Letters: > Lists > Phone Numbers > Name/Signature > Your checks Telephone Use Distance Vision: > Can you see faces? > Can you see street signs? > Can you go to the movies? > Can you see TV?