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

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

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?

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.

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?

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.

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

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

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

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

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.

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.

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.

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!

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!

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.

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?

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.

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.

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.

99000 vs. 92000 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 99000 than 92000 as these encounters typically require more patient counseling and education

92000 vs. 99000 Requirements for 92000 codes are more general than those for the 99000 codes > 92002-92014 require history and a chief complaint > 99000 series requires considerable more documentation, particularly in certain levels of history of present illness, review of systems and past/family/social history

92000 Codes Can be used to report both > Medical eye care visits > Routine eye care > Many insurance carrier are considering the 92000 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)

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)

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!

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

Comprehensive Exams- 92004/92014 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.

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)

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!

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

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

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.,

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

Grading the Office Visit New Patient Level Code History Exam Medical Decision 1 99201 Problem Focused Problem Focused 2 99202 Expanded PF Expande d PF Straight Forward Straight Forward Time (Minutes) 3 99203 Detailed Detailed Low 30 4 99204 Comprehensive Comp Moderat 40 e 5 99205 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

Example of 99203 Code History Exam Medical Decision 99201 Problem Focused Problem Focused 99202 Expanded PF Expanded PF Straight Forward Straight Forward Time (Minutes) 99203 Detailed Detailed Low 30 99204 Comprehensive Comp Moderate 40 99205 Comprehensive Comp High 50 10 20

Documentation Guidelines - 99203 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

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

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

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?

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.

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

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.

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

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.

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

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

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.

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

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

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

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

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.

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)

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

Prolonged Services CPT 99354 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 99354 in conjunction with 99201-99215, 99241-99245, 99324-99337, 99341-99350, 90809,90815) 99355 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

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 99215. > 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 99354.

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 99355 may be used to report each additional 30- minutes beyond the first hour of prolonged service Example: > A physician performed a visit that meets 99213 and the total duration of direct patient care (including the visit) was 65-minutes. The physician bills code 99213 and one unit of 99354 > A physician performed a visit that meets 99212 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.

Prolonged Service Codes Has to be Direct Patient Care time with the Provider CPT Code Typical Time Threshold to Bill 99354* Threshold to Bill 99355 ** 99203 30 60 105 99204 45 75 120 99213 15 45 90 99214 25 55 100 * 99354 is billed only once ** 99355 can be billed multiple times in 30-minute increments

Prolonged Services Total Duration of Prolonged Services Less than 30-minutes 30-74 minutes (30-minutes to 1 hour and 14-minutes) 75-104 minutes (1 hour 15-minutes to 1 hour and 44-minutes 105 or more (1 hour 45-minutes or more) Codes Not Reported Separately 99354 x 1 99354 x 1 + 99355 x 1 99354 x 1 + 99355 x 2 (or more each additional 30-minutes)

Specialized Codes If MEDICALLY NECESSARY, practitioners may wish to consider the following specialized CPT-4 Procedures: > Extended Ophthalmoscopy -92225/92226 > Visual Fields - 92081-92083 > OCT 92133; 92134 These codes require an "Interpretation and Report

Specialized Codes Ocular Photography - 92250 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

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

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

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

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)

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

Refraction A specialized ophthalmological procedure - CPT 92015 which is a non-covered service by CMS definition Low VISION Refraction - no specialized CPT codes > Single Level vs. Multiple Levels

Refraction Each practitioner may wish to consider setting multiple refractive fees > Level 1 - Simple Refraction 92015 > Level 2 - Simple Low Vision Refraction - e.g. Low Vision Patient > Level 3 - Complex Low Vision Refraction - e.g. Legally Blind Patient

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

Example Date CPT Total Fee Billed to Insurance Carrier Patient Responsibility 1-1-12 99204 $150 $130 $20 (Co-pay) 1-1-12 92015 $100 0 100 1-1-12 92225 $100 $80 $20 1-1-12 92392 $50 0 $50 (LV Device) Total $400 $210 $190

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

ICD-9 Codes For Vision Impairment That Support Medical Necessity for Rehab Be = better eye Le= lesser eye 368.41 SCOTOMA central area 368.45 Generalized contraction or constriction 368.46 Homonymous bilateral field defects 368.47 Heteronymous bilateral field defects 369.01 Be - total impairment Le - total impairment 369.03 Be - near-total impairment; Le- total impairment 369.18 Be - moderate impairment Le - profound impairment 369.22 Be - severe impairment Le - severe impairment 369.24 Be - moderate impairment Le - severe impairment 369.25 Be - moderate impairment Le - moderate impairment

ICD-9 Codes For Vision Impairment That Support Medical Necessity for Rehab 369.04 Be - near-total impairment Le - near-total impairment 369.06 Be - profound impairment Le - total impairment 369.07 Be - profound impairment Le - near-total impairment 369.08 Be - profound impairment Le - profound impairment 369.12 Be - severe impairment Le - total impairment 369.13 Be - severe impairment Le - near-total impairment 369.14 Be - severe impairment Le - profound 369.16 Be - moderate Le - total impairment 369.17 Be - moderate impairment Le near-total

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

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.

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

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

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

Example Example 1 > Face-to-Face Time 25 minutes (CPT -4) > Total Counseling Time 15 minutes > Level of Care 99214 (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)

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

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

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

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

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.

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

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

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.

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!

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

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

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

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

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 2050. 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.

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.

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

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

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.

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!

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

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

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

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

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

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

End Result Altered Quality of Life

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!

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

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)

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

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

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

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

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

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

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

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

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.

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

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

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)

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.

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

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

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

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 97002 or 97004 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 92000 or 99000 Therapy Rehab Codes 97535, etc.

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

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.

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?

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)?

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

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

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.

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.

Initial Visit to Optometrist: Initial E & M Visit (99000 code) or Appropriate 92000 (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.

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?

Therapy Evaluation Visit Impaired Compensation Evaluation Goal of this Visit: > To Access the Rehabilitee s Potential» Use E & M or 92000 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

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!

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

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

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:

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:

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

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?

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?

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?

Difficulty with ADL s (Con t) Can you operate? > The stove > The microwave > The calculator > The thermostat > The TV/VCR remote > The computer > Toaster/blender > Coffee pot

Difficulty with ADL s (Con t) Can you identify? > Food in the refrigerator > Clothes in the closet > Food in cupboards > Colors > Cleaning Solutions > Medicines > Can you apply make-up? > Can you dress? > Can you groom/shave? > Can you pour liquids? > Can you clean your house? > Can you use your keys? > Can you change light bulbs? > Can you do home repairs? > Can you socialize with friends? > Can you play cards?

The Treatment Plan All Rehabilitative services (including VISION) should be provided in accordance with a written evaluation and treatment plan!

The Treatment Plan The initial treatment plan should include: > An initial assessment which documents the level of visual impairment and a statement as to whether there is a restorative component > A plan of care identifying special goals to be fulfilled during rehabilitation and a definition of the specific services to be provided during the course of rehabilitation > A reasonable estimate of when goals will be reached and the frequency at which services will be provided > Possible tests to assure the cognitive function of the patient (e.g., The mini-mental examination) and the VFQ-25 (Not required for NY)

The Treatment Plan (Continued) > Rehabilitation program and services for beneficiaries with vision impairment may include the following example of Medicare covered therapeutic services:» Mobility» ADL; and» Other rehabilitation goals that are medically necessary

Treatment Plan Patient s Name: Date of Birth: Date: Level of Visual Impairment: > Best Corrected Acuity OD: > Best Corrected Acuity OS: > Visual Field Loss: > The patient is experiencing vision problems secondary to: - Disease: ICDA Codes: - Disease: ICDA Codes:

Treatment Plan (Con t) Is there a Restorative Component? Yes No Patient s Ability to Comprehend (Cognitive Function): Adequate Inappropriate Functional Ability for Rehabilitation: Adequate Inappropriate Patient s Chief Complaint: Secondary Factors:

Treatment Plan (Con t) The patient demonstrates the following symptoms. Related to their vision deficits that may impede basic activities of daily living and mobility - Check ALL that applies > Patient has a history of falls which may impair ADL performance and mobility > Patient suffers from diplopia, nystagmus or which may impair his/her ability to read, write, or ambulate

Treatment Plan (Con t) > Patient has problems with decreased visual scanning and search which may impair ADL performance and mobility > Patient has restricted visual fields which may impair ADL performance and mobility > Patient has limited useable remaining vision > Patient has a central scotoma which may impair ADL performance and mobility as well as the ability to read write and ambulate

Treatment Plan (Con t) The Above Checked Items may impair the following (check those that apply) mobility/safe travel in the environment managing personal finances managing nutritional needs managing ADL community/work integration skills managing health needs

Treatment Plan (Con t) Assessment and Plan: The patient will benefit from the following: > ADL training in:» Optometric Office» Rehab Office»Both > Orientation and Mobility: Where: > Neuromuscular rehabilitation (eye-hand coordination, scanning, etc.) in an Optometric Office

Treatment Plan (Con t) Plan of Care with Goals: > A) increase the patient s effective use of optical devices to read materials needed for daily living B) increase the patient s ability to write legibly to complete communications such as answering mail C) increase the patient s ability to complete financial transactions and manage financial affairs independently D) Increase the patient s ability to complete self-care and homemaking activities with efficiency, independence and safety E) Increase the patient s ability to engage in leisure & community activities F) Other:

Treatment Plan (Con t) Appropriate ICDA Codes: 99 99 99 99 99 Specific Rehabilitation Services to be Provided: Duration of Program: a) Estimate of time for completion: b) Frequency of Services: c) Re-evaluation Date: > Prognosis for Training Success: - Excellent/Good/Fair/Poor - When Will Goals Be Met: 1 Month 2 Months 3 Months - Number of Visits Required:

Treatment Plan (Con t) Impressions/Recommendation: Based upon the functional vision limitations and visual signs and symptoms, the patient s ocular diagnoses are inhibiting his/her personal independence and safety. I am recommending that this patient receive REHABILITATION FOR PATIENTS WITH VISUAL IMPAIRMENT. O.D. Date:

ICD-9 Codes For Vision Impairment That Support Medical Necessity for Rehab Be = better eye Le= lesser eye 368.41 SCOTOMA central area 368.45 generalized contraction or constriction 368.46 homonymous bilateral field defects 368.47 heteronymous bilateral field defects 369.01 Be - total impairment Le - total impairment 369.03 Be - near-total impairment Le total impairment

ICD-9 Codes for Vision Impairment (Con t) 369.04 Be - near-total impairment Le - near-total impairment 369.06 Be - profound impairment Le - total impairment 369.07 Be - profound impairment Le - near-total impairment 369.08 Be - profound impairment Le - profound impairment

ICD-9 Codes For Vision Impairment (Con t) 369.12 Be - severe impairment Le - total impairment 369.13 Be - severe impairment Le - near-total impairment 369.14 Be - severe impairment Le - profound 369.16 Be - moderate Le - total impairment 369.17 Be - moderate impairment Le near-total

ICD-9 Codes For Vision Impairment That Support Medical Necessity for Rehab 369.18 Be - moderate impairment Le - profound impairment 369.22 Be - severe impairment Le - severe impairment 369.24 Be - moderate impairment Le - severe impairment 369.25 Be - moderate impairment Le - moderate impairment

CPT Codes for Visual Rehabilitation There are several CPT codes available LMRP usually indicate which ones they will cover The New York LMRP is comprehensive and serves as a great resource Visual Rehabilitation can also be utilized for a stroke patient who has a significant visual field loss (i.e. Hemi Visual Field Loss)

Rehabilitation CPT Codes 97112 therapeutic procedure, one or more areas, each 15 minutes; neuromuscular re-education of movement, balance, coordination, kinesthetic posture and proprioception 97116 gait training (includes stair climbing) consider prism training 97530 therapeutic procedure, direct (one on one) patient contact by the provider use of dynamic activities o improve functional performance, each 15 minutes 97532 development of cognitive skills to improve attention, memory, problem solving, (includes compensatory training), direct (one-on-one) patient contact by the provider, each 15 minutes

Applicable Therapeutic Procedures 97533 sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) patient contact by the provider, each 15-minutes 97535 self-care/home management training, e.g., Activities of daily living, compensatory training, meal preparation, safety procedures, and instruction in use of adaptive equipment, direct one-on-one contact by provider, each 15-minutes 97537 community/work reintegration (e.g., Shopping, transportation, money management, avocational activities and/or work environment modification analysis, work task analysis, direct one on one contact by provider, each 15-minutes

CPT 97530 CPT 97530 Therapeutic activities direct (one to one) patient contact by the provider. Use of dynamic activities to Improve functional performance. Each 15 minutes > Visual scanning > Hand/eye manipulation tasks > Peripheral awareness > Eccentric Viewing strategies > Sensory Integration > Stroke issues and visual impairment

Eccentric Viewing Exercise Dr. Goodrich

Wayne Electronic LaBarge Designed patterns Customize patterns Auditory feedback Metronome

CPT 97535 Self-care/home management training (e.g. ADL & compensatory training, meal management, safety procedures and instruction in the use of adaptive equipment. Direct (one-to-one) contact by the provider. Each 15-minutes > Meal preparation feeding, eating, cooking, cleaning > Safety procedures concerns including medication routine and medical management > Grooming/hygiene, appliance operation, task lighting and contrast strategies, object placement and organization > Integration of assistive technology (adaptive devices -optical and non-optical devices) for these tasks

Teaching Home Cooking

Teaching How to Use an Oven

CPT 97537 CPT 97537 Community/work reintegration training, transportation, money management, avocational activities and/or work environmental/modification analysis, work, task analysis.direct (one-to-one) contact by the provider. Each 15-minutes > Education goals > Personal business management > Transportation options > Simulated work station > On site work station analysis/modification > Integration of assistive technology for these tasks > Shopping > Money management/personal business management > Avocational activities

Teaching Reading with a Magnifier

Rehabilitation Teaching

Therapy Sessions Generally there is maximum of 10 sessions allowed over a 90 day period ranging from 30-60 minutes per session. CPT Codes Each is Billed in 15 minutes intervals: 97112;97116;97530;97532;97533;97535;97537 Billing: > Eye care previews performs all of these sessions by billing appropriate rehabilitative codes > Eye care provider performs some of these sessions and refers to other disciplines for those services he/she cannot perform in the office (i.e. home teaching, O&M) > Eye care provider refers the patient out for all rehabilitation (e.g. PT,OT, State or Non-Profit Agency)

Progress Note One for Each Visit Initial Assessment: Diagnosis: > Name: Date: Best-Corrected Distance Visual Acuity: O.D. O.S. Diagnosis: ICDA: ICDA: > Are you involved in receiving any home health care services? Yes No

Progress Note: (Con t) CPT: 97112: Neuromuscular re-education 97116: Gait Training 97530: Improve functional performance 97532: Cognitive Skills 97533: Sensory Integration 97535: ADL (meals, safety, adaptive equipment) 97537: Community/Work Integration

Progress Note: (Con t) Session #: 1. Goal: CPT: UNITS: Activity: Low Vision Devices Used: Other Considerations: Lighting Field of View _ Working distance Focusing Ability _ Mobility Eccentric Viewing Care of device including changing battery Success: Goal Achieved: Yes No

Progress Note: (Con t) Add as many activities as you perform in a given session Document if family members are involved; document care coordination, and consultation Each patient encounter must have a separate progress note can be written, graph, flow sheet Report any changes in objective and measurable terms as related to the treatment goals Report any adverse reactions to treatment When progress is slower than expected or not being made, document why

Measurable Goals - Samples To my knowledge there are no standardized goals for Vision Rehabilitation as of yet. They do exists for OT, PT, etc.. Possible vision rehab goals are as follows: > A. When asked, the patient will describe the effects of size, contrast, and illumination on environmental visibility to a level that demonstrates an adequate knowledge. > B. When asked, the patient will describe his or her best eye placement for eccentric viewing to a level that demonstrates adequate knowledge.

Measurable Goals > C. When presented with a stand magnifier to perform an activity of daily living, the patient will read labels, dial setting, medication bottles, etc.. with 90% accuracy. > D. When presented with a stand magnifier, the patient will read and perform the activity of daily living with 90% accuracy > E. When presented with a head borne microscope, the patient will read and describe material with 90% accuracy. > F. When presented with a telescope, the patient will use it to view television and for other activities of daily living at a level sufficient to meet daily needs > G. When presented with a standard signature guide and pencil, the patient will write his or her signature legibly with 90% accuracy.

Measurable Goals (Con t) > H. When presented with a full page writing guide, the patient will write a one-page letter with 90% of the words legible. > I. When presented with a rotary dial telephone or a push bottom phone and 10 phone numbers, the patient will successfully contact 9. > J. When presented with a watch, the patient will consistently read the time and set it to within 5 minutes of the correct time. > K. When presented with a clock, the patient will consistently use all its functions to a level sufficient to meet his or her needs.

Measurable Goals (Con t) > L. When presented with coins or bills, the patient will identify them correctly with 90% accuracy. > M. When presented with checks (regular or adaptive), the patient will write checks correctly with 90% accuracy. > N. When presented with an adaptive device, the patient will read and set a thermostat with 90% accuracy. > O. When presented with a regular or self-threading needs and the appropriate adaptive devices, the learner will thread the needle accurately.

Physician Re-evaluation Periodic follow-up and evaluation verification should be documented by the physician during the course of rehabilitation Eye Care Providers (OD and MD) doing the rehabilitation monitors the patient s success using 92000 or 99000 codes Eye care Providers who refers the patient out sees the patient every 30 days and assesses progress using 92000 or 99000 codes

Physician Re-Revaluation When the rehabilitation sessions extend beyond four weeks, a monthly report must be provided by the person performing the services and reviewed and signed by the physician (may vary from state to state). If additional sessions are medically necessary, medical record documentation must indicate the need for additional sessions.

Re-evaluation: Initial Goals: ADL Mobility Neuromuscular > Extent to which each goal was met: a) Increase the patient s effective use of optical devices to read materials needed for daily living Goal met: yes no Somewhat Comments: b) Increase the patient s ability to write legibly to complete communications such as answering mail Goal met: yes no Somewhat Comments: c) Increase the patient s ability to complete financial transactions and manage financial affairs independently Goal met: yes no Somewhat Comments: d) Increase the patient s ability to complete self-care and homemaking activities with efficiency, independence and safety Goal met: yes no Somewhat Comments: e) Increase the patient s ability to engage in leisure and community activities Goal met: yes no Somewhat Comments: f) Other: Goal met: yes no Somewhat Comments:

Re-evaluation Every 30 days, the above progress evaluation will be completed. Summary: a) Patient has reached his/her goals and rehabilitation is complete. The patient will be seen again in. b) Patient requires additional rehabilitation. Additional sessions are needed. Next re-evaluation will be performed in days c) Patient cannot tolerate Visual Rehabilitation and the program is terminated Additional CPT Codes: Sign and Date:

Discharge Summary A final form (discharge summary) should be prepared for each patient after the last visit Includes a discussion of the findings on the last visit and how this compares to the initial status Reason for discharge: goals achieved or patient declines to continue (sick or transportation problems) Summary of progress Patient s current physical and functional status Discharge plan including home instruction Discharge date and signature

Final Discharge Summary A Mandatory Requirement: > Indicate the extent to which each goal was met: a.) Increase the patient s effective use of optical devices to read materials needed for daily living Goal met: yes no somewhat Comments: b.) Increase the patient s ability to write legibly to complete communications such as answering mail Goal met: yes no somewhat Comments:

Final Discharge Summary c.) Increase the patient s ability to complete financial transactions and manage financial affairs independently Goal met: yes no somewhat Comments: d.) Increase the patient s ability to complete self-care and homemaking activities with efficiency, independence and safety Goal met: yes no somewhat Comments:

Final Discharge Summary e.) Increase the patient s ability to engage in leisure and community activities Goal met: yes no somewhat Comments: f.) Other: Goal met: yes no somewhat Comments: Next Exam Date:

The Treatment Program Therapy sessions are programs for the patient in the home (12),custodial care facility (33), independent clinic (49), outdoors (15), or the office setting (11). The ordering/referring physician s name and UPIN is required in Items 17 and 17A on the CMS 1500 form. If the performing physician is also the ordering physician, the physician uses his/her own UPIN. A plan of care is established with the patient that documents the patient s limitation in ADL resulting from the vision loss, sets achievable functional goals for ameliorating those limitations, outlines the procedure by which the goals will be achieved, and establishes a time frame for treatment.

Rehabilitation Therapy Techniques There is no-cook approach Each patient should receive his/her individualized treatment program You will need to do your homework on developing techniques for training Spend time with a Rehab Teacher (trained to help visually impaired patients.

Documentation Requirements Written documentation by the person conducting the therapy sessions shall include: > Initial assessment; > Plan of care with specific goals > Progress notes describing the content and number of time units for each session > Discharge summary documents the extent to which each goal in the plan was achieved, which is to reviewed and signed by the physician

In Office Skills Taught to Patients Requiring Vision Rehabilitation 1. Safe operation of equipment» Microwaves; Thermostats, etc. _With Low Vision Devices 2. Medication Management _With Low Vision Devices 3.Home Finances» Checkbook; Bank Account; Paying Bills, Other: 4. Writing _With Low Vision Devices a. Guides b. Writing Implements 5. Telephone Dialing _ With Low Vision Devices 6. Money Identification _ With Low Vision Devices 7. Personal Organization System for Mail _With Low Vision Devices 8. Orientation in Space _With Low Vision Devices 9. Spatial Relations _With Low Vision Devices 10. Lighting Management _With Low Vision Devices 11. Environmental modification _With Low Vision Devices 12. Eccentric Viewing/Scanning _With Low Vision Devices

How Do I Measure Specific Goals? Goals to Consider: > Increase baseline reading speed with a magnifier > Increase scanning ability I saw three letters and now I see five > Finding a specific number in the phone book > Reading newspaper sized print for 15 minutes > Paying rent on your own with prescribed low vision devices > Home management/meal preparation:» Patient will follow a 5 step written recipe to prepare a cold meal with the use of a magnifier > Avocational activities:» Patient will successfully identify a tape (with a magnifier) for talking books and load the machine appropriately 5 times > Leisure activates:» Patient will participate in watching a TV program with the use of his/her telescope

Other Factors to Consider when trying to increase patient goals: > Working distance > Lighting > Positioning of objects > Steady eye strategy > Low vision device maintenance > Eccentric fixation > Contrast sensitivity

Therapy Techniques Telephone Usage: Finding a specific number in the phone book with low vision devices Dialing a phone correctly with low vision devices or specialized phone dials Correctly finding phone numbers in a telephone directory CPT Codes: 97533 & 97535 Reading: Correctly reading newspaper sized print for 15 minutes Correctly seeing TV times/tv channels in a TV guide Accurately reading bills with low vision devices CPT: 97535 Money Management: Paying rent or electrical bills on your own with prescribed low vision devices check writing guides Identifying coins and bills correctly with prescribed low vision devices Sorting mail with low vision devices Reading bill accurately with low vision devices Accurately completing a check/money order CPT: 97535 & 97537 or

Therapy Techniques/Goals Telling Time: Correctly setting watch with low vision devices Correctly seeing a clock with low vision devices or eccentric viewing CPT: 97533, 97535; 97537 Hobbies: Correctly threading a needle to sew with appropriately prescribed low vision devices or adaptive devices Successful sewing/knitting with low vision devices or adaptive equipment Accurately seeing photographs with low vision devices Playing cards/bingo accurately with low vision devices Appropriately doing crossword puzzles with low vision devices Performing home repair activities with low vision devices CPT: 97535 & 97537

Therapy Techniques/Goals Shopping: Reading price tags correctly with low vision devices Correcting locating an object in an aisle Writing a grocery list accurately CPT: 97535 & 97537 Cooking/Eating/Meal Management/House Cleaning: Safely seeing and setting the stove control settings (or the flame) with low vision devices Correctly using a microwave to heat up a meal with low vision devices Correcting seeing food on a plate Pouring fluids accurately with low vision devices Appropriately cleaning one s house or telling if one s house has been cleaned Correctly identifying food labels with low vision devices Correctly identifying panel ingredients on a food label Accurately measuring ingredients Identifying food and cleaning products correctly with magnifiers Accurately timing food/ determining when it cooked CPT 97535

Therapy Techniques/Goals Computer Usage: Accessing the Internet with low vision devices or adaptive equipment Correctly using word processing programs with low vision devices CPT: 97535 & 97537 Watching TV: Seeing the TV appropriately with telescopes Accurately using the remote with low vision or adaptive equipment CPT: 97535 & 97537 Grooming: Appropriately applying make-up on yourself with low vision or adaptive equipment Appropriately combing one s hair with low vision devices or adaptive equipment Laundry preparation CPT: 97535 Mobility: Crossing street safely with specifically prescribed low vision devices or adaptive equipment Appropriately traffic lights with specifically prescribed low vision devices or adaptive equipment Identifying street sign accurately Correcting seeing house/apartment numbers Accurately seeing curbs/steps CPT: 97535 & 97537

Therapy Techniques/Goals Medication Bottles/Rx Management: > Correctly identifying labels on medication bottles > Correctly placing pills in a bill sorter/holder > Correctly filling an insulin syringe CPT: 97535 Writing: > Correctly signing a check with low vision or check writing guides > Correctly addressing an envelope with low vision devices or writing guides CPT: 97535 & 97537 Object Placement and Organization CPT: 97535 Visual Scanning Activities CPT: 97530 Eccentric Viewing CPT: 97530

Completion of the Program and Maintenance When the patient has shown no progress in a reasonable period of time, it will be assumed that rehabilitation services will be considered to have reached a stable state or plateau, and training will be considered maintenance, which is non-covered, unless appropriate additional medical documentation indicates the medical necessity for continued training. May also vary from LCD to LCD

Sample Treatment Plan: Week 1: > 97112 X 2 + 97530 x 1 + 97537 x 2 (70-minutes total) Week 2: > 97112 x 2 (30-minutes) + 97530 x 2 (40-minutes) Week 3: > 99212/92012 (re-assess progress) + 97530 x 2 (40-minutes) + 97537 x 3 (50-minutes)

Sample Treat Plan: Week 4: > 97535 x 4 (70-minutes) Week 5: > 99212 (re-assess progress) + 97535 x 2 (40-minutes) + 97537 x 2 (33-minutes) Week 6: > 99213/92012 final evaluation and management reinforcement of learned skills (appropriate rehab codes)

Billing Therapeutic Services Most therapy is short term and intensive Sessions are generally conducted over ten (10) encounters in a 90-day period of time with intervals appropriate to the patient s needs. (Check your LCD) Patient s usually receive therapy 1-2 time per week, and not less frequently than once every two weeks. The sessions are generally 30-60 minutes in duration. If more sessions are needed, medical record documentation is required Patients may require additional therapy if there has been a significant change in their visual status requiring additional training to manage with a decreased level of function. Reimbursement for VISION rehab may be included in annual therapy caps

Billing Therapeutic Services > Fee Reimbursement is Approximately $25-35 per 15-minute session (Reimbursement varies with CPT Code) > Services are face-to-face time between the patient and physician or therapist > A minimum of 15-minutes of face-to-face time for each unit is required:» If less than 15-minutes no services should be billed» If less than 30-minutes only bill one unit» If less than 45-minutes bill 2 services» Three units require 45 to 60 minutes» Four Units requires more than 60-minutes

Individuals (Patients) are Independent when: they perform tasks themselves using appropriate adaptive equipment or alternative task methods as required they perform tasks in an adapted environment

Medicare Coverage If a service is to qualify for Medicare coverage, the provider must maintain detailed documentation. Not only must this documentation be comprehensive consistent and chronological, it must also be understandable to an outside reviewer

Medicare Coverage The documentation should also use the physician s evaluation of the patient to justify all management decisions The documentation must also support the CPT codes billed Therapy Cap for OT/PT

The Treatment Program Upon return for each follow-up visit, the patient should be asked to demonstrate the use of aids and techniques learned in the previous session.

Completion of the Program and Maintenance The program of rehabilitation will be judged to have been completed when the treatment goals have been attained and any subsequent services would be regarded a maintenance of functional ability.

Additional Billing Guidelines You need to use an ICD-9 code that indicates the level of visual impairment GO Services delivered under an outpatient OT plan of care (Tracking item) GP Services delivered under an outpatient PT plan of care CCI Edits > You cannot bill certain pairs on the same day > 97530 cannot be billed with 97535

Additional Billing Guidelines Unbundling and Modifier 59 Modifier 59 may be used to differentiate between services. Using modifier 59 means that the services performed are medically necessary and distinct separate services from each other. Modifier 59 tells Medicare that the procedures may look related but indeed they are distinct and separate services. This may represent a different session or patient encounter, different procedure or surgery, different site or organ system, or separate injury. > E.g., If you bill both CPT 97530 & 97535, one service will be rejected as part of the CORRECT CODING INITIATIVE unless you add Modifier 59 to the bundled CPT service (CPT 97535)

Who Can Provide These Services? SUPERVISION: > Services may be provided by a physician as defined in Section 1861 (1) and (4) of the Social Security Act, a qualified OT, or a qualified PT. > Services furnished by an employee of the physician may only be provided incident to the physician s professional services, must be furnished under the physician s direct personal supervision, and must meet other incident to requirements provided in Section 2050 of the Medicare Carrier s Manual.

Who Can Provide These Services? CMS will no longer pay for therapy services incident to a physician s services unless the provider is a licensed provider (MD, OD, OT, PT) Based upon new definitions and rules, O&M specialists, certified low vision therapists and rehab teachers may NOT provide this type of therapy The only people that can perform these services are MD s, OD s, OT s and PT s.

Incident To Incident to services are integral but incidental to the physician s services. Measurement of a visual acuity or blood pressure, or recording a visual field or EKG are skills easily taught to a technician and are considered an integral but incidental part of physician services. On the other hand, knowledge of optics and teaching ability are necessary to design, execute, and adjust a vision rehab plan requires extended formal education and clinical experience. Therapeutic services and treatment planning services are not incidental to low vision rehab; they are determinants of success and should not be performed without proper training.

Incident To A technician, for example, a certified ophthalmic assistant or certified optometric technician may collect data incident to physician's services as part of the low vision evaluation or progress assessment, which are evaluation and management services. However, only a physician, OT, or PT, may provide low vision rehabilitation!

Supervision Services furnished by an employee of the physician may only be provided incident to the physician s professional services under the physician s direct personal supervision and must meet other incident to requirements in Medicare manuals.

Who Can Provide These Services? Old Definition Direct supervision means that a physician must be in the immediate vicinity of the rehab program, and immediately available or accessible for consultation or emergency. It does not require that the physician be physically present in the room itself. In NY State, PT s and OT s were not able to accept orders from OD s. OD s until 2011.

Who Can Provide These Services? New Definition The new rules which are to be implemented on June 6, 2005, require that the person who furnishes the rehabilitative service, must, at least, be a graduate of a program of training for one of the therapy services (OT and PT). Regardless of any state licensing that allows other health professionals to provide therapy, Medicare is authorized to pay only for services provided by those trained specifically in physical therapy, occupational therapy or speech-language pathology. THIS MEANS THAT THE SERVICES OF A LOW VISION SPECIALIST MAY NOT BE BILLED.

Section 230.5 - Continued Services may not be billed as therapy services incident to a physician s service if the service is provided by a person trained in any other profession, or licensed or certified in any other profession including physical therapist assistant and occupational therapy assistant, athletic trainer, or LOW VISION SPECIALIST.

Who Can Provide These Services? (Con t) OT services cannot be provided without a referral by a physician. The initial assessment must be done by a physician and billed by the physician. If there are no restrictions in state laws, optometrists may refer patients for occupational therapy services. Optometrists may also establish and review the occupational treatment plan. This must not be in violation of any state licensure law.

Who Can Provide These Services? (Con t) The physician or therapist is required to have direct one-toone contact when therapeutic procedures are billed.

Coverage Denials: Patients who have poor rehabilitative potential or patients who are unable to cooperate in the program Coverage will be denied when there are no clear goals are definable

Tests and Measurements Possibly another code to add for testing (E.g. the impaired compensation visit CPT 97750 Physical performance test or measurement (e.g., musculosketel, functional capacity), with written report Tests and measurements that are performed over and above the evaluation. It includes: computerized capacity evaluation, balance, isokinetic testing, and may also include work site evaluation

Tests and Measurements CPT 96115 neurobehavioral status exam with interpretation and report (clinical assessment of thinking, reasoning and judgment, e.g., acquired knowledge, attention, memory, visual spatial abilities, language functions, planning Per hour

Visual Impairment Tests Visual Fields as appropriate Color Vision Dark Adaptation Contrast Sensitivity Functional Amsler Grid

99750 Physical Performance Tests Used per 15-minutes of testing Include an analysis, summary, and interpretation of the test results Examples may include reading speed, speed vs. character size, fine motor control (eye-hand coordination), etc.

Will The Patient Benefit From Low Vision Rehabilitation? One can measure this using the national eye institute visual function questionnaire, (VFQ-25) which was developed by the Rand institute. Currently not necessary for NY State A score of 70 or less indicates a need for rehabilitation.

VFQ-25 Sample Questions Can you apply make-up or shave? Do you see well enough to use public transportation? Can you identify denominations of money or sign a check? Are you visually able to read price tags, labels, or large print books? Can you identify the color of your pills?

Does the Patient Have a Clear Potential for Improvement? This can be assessed using the mini-mental examination a neurological screening test Currently not necessary for NY An exam score of 20 or greater could be used to assess the patient s potential to benefit from a rehabilitative program

Summary: The Goals of Vision Rehabilitation To restore independence, safety, and quality of life To prevent falls, burns and other injuries Can enable people who are blind and partially sighted to practice healthy behaviors in diet, exercise, and disease management - thereby reducing health care and dependency costs for older Americans. Vision impairment is the cause of 18% of hip fractures annually (Farmingham Eye Study) if only 1 in 5 of hip fractures due to vision impairment was prevented each year, the annual cost savings would be more than $440 million In addition to health risks, patients often suffer from fear, anxiety, depression, loss of control and loss of self-esteem

Vision Rehabilitation: Prognosis & Follow-up The prognosis for success with low vision rehabilitation depends on a variety of factors, including, but not limited to, the ocular condition causing the visual impairment, the nature and extent of vision loss, the goals of rehabilitation, the patient s attitude, motivation, and expectations, and the clinician's attitude and motivation. The number and frequency of follow up visits will depend on the stability of the eye condition and the patient s response to therapy and specific visual devices. The patient s needs and vision may change over time. Once the specific goals of rehabilitation have been met or addressed, follow up to assess ongoing concerns should be continued on a regular schedule, as determined by the clinician and patient. The follow up should include ongoing assessment of eye health and vision status.

Does Every Low Vision Patient Require Vision Rehabilitation Probably No! Every low vision patient should be instructed (or reinstructed) in how to use a newly prescribed low vision device. (Not covered by Medicare) as this is not REHAB Every low vision patient should be assessed and if required, given rehabilitation therapy in how to reach their stated functional goals. (Covered by Medicare)

Can I use a Rehab Code for a Single Visit? Some CPT codes have been designated only therapy codes while others have been designated sometimes therapy codes If you use an designated therapy code, you are billing with a GO modifier (for the claim to be paid and tracked as rehab) you must be working under a treatment If you use a CPT code designated as sometimes therapy, you may be able to bill a single visit.

What are the Sometimes Therapy Codes 97532 development of cognitive skills to improve attention, memory, problem solving, (includes compensatory training), direct (one-on-one) patient contact by the provider, each 15 minutes. Sometimes Therapy Codes can be billed without a treatment plan in place.

Remember Teaching a patient to use a magnifier is NOT Vision Rehabilitation Teaching a patient to use a magnifier to see his/her medication bottle is Vision Rehabilitation as long as the patient cannot accomplish this functional goal. Rehabilitation uses prescribed low vision devices along with therapy techniques and adaptive equipment to perform daily functional activities such as writing, bill paying, telling time, managing medications, managing nutrition, safe travel, etc.

Conclusion We are going in the right direction but we are not there yet Eye care providers who render low vision services are uniquely qualified to manage visually impaired patients in that they can assess ocular status, evaluate visual functioning, prescribe low vision devices, and provide therapeutic intervention or coordinate other forms of care to improve the functioning of the patient s impaired visual system. Low Vision Rehabilitation can significantly improve the quality of life for visually impaired patients.

We re Not There Yet! Low Vision Exam not Covered Poor Definitions of Low Vision Exam/Vision Rehabilitation

Summary Be accurate Be consistent Be careful Follow the rules

Take Home Message The goal of vision rehabilitation is to restore independence, safety and the quality of life.

Take Home Message Every low vision patients should be given instructions on how to use LV devices. (Not Covered by Medicare)

Take Home Message Every low vision patient should be assessed whether vision rehabilitation will enable them to reach their functional goals (covered by Medicare).

Most Importantly If low vision is not your expertise, please refer patients to those who have the potential to improve their functional life.

Questions?

Community Services Alcoholics Anonymous Blindness and Visual Services Child Guidance Center Community Health Nursing Services Department of Health and Human Services Dept of Social Services Educational Services Centers Family outreach Centers Family Service Center Handicapped Parking information Head Injury Foundation Health Department Home Health Care, Inc. Library of Congress Meals on Wheels National Asso. for Parents of the Visually Impaired National Asso. For the Visually Handicapped Psychiatric hospitals Senior Citizens Taxi Program Senior Health Program Sheltering Arms Taping for the Blind Transportation Services Veterans Administration Visiting Nursing Association Voting Assistance Hotline

Clinical Observation Indicating Visual Impairment 1. Near Visual Acuity: Ask the patient to read a line of standard or large print in a newspaper, magazine or book. The approximate size of the print is. The patient: > complains that the print looks fuzzy > complains of an inability to bring the print into focus > continuously adjusts the length of the page trying to bring it into focus > complains that the print is too small to read > brings the page of print in very close to try to read it > shifts the page of print to one side of midline to read it > views the print out of the corner of one eye or uses eccentric viewing > says it s impossible to read > Other:

Clinical Observation Indicating Visual Impairment 2. Distance Visual Acuity: Ask the patient to look at a person across the room. The patient: > complains of an inability to recognize faces > use eccentric viewing to see faces > gets up and walks closer to see the person > states that his/her vision fluctuates too much > asks for additional light in order to see the person > says it s impossible to do > Other:

Clinical Observation Indicating Visual Impairment 3. Contrast Sensitivity: Ask the patient to fill a clear glass with water from the tap or a pitcher to within ½ inch of the brim. The patient: > complains that they can t see the level of water as it rises up the glass > overfills the glass > uses the tip of a finger over the glass brim to determine water level > moves in very close to the glass to view the water level > tilts the glass back and forth to create movement to assess water level > Other: 4. Contrast Sensitivity: Ask the patient to fill a black cup with milk to within ½ inch of the brim and compare with his/her performance using the clear glass and water.

Clinical Observation Indicating Visual Impairment 5. Mobility: Observe the patient ambulate in the office in an environment of low contrast (curb outside of the office, areas with poor illumination, furniture that does not contrast from surrounding features, door frames that do not contrast from the doors, etc.). The patient: > hesitates when approaching curb or subtle changes in support surfaces > misses curb or does not see it until directly on top of it > bumps into or comes very close to low contrast obstacles > uses hands to guide around an obstacle > complains that he/she cannot recognize faces > asks for additional lights > is unable to accurately distinguish color of similar hues > is unable to complete to task > Other:

Clinical Observation Indicating Visual Impairment 6. Visual Field Defect: Observe the patient ambulate through the office or outside of the office. The patient: > collides or comes very close to obstacles consistently on one side > stares straight ahead at the floor immediately in front of his/her or off to one side > stays very close to one side of the wall when ambulating > uses fingers to trail the wall to actually guide self > refuses to take lead when ambulating; prefers to walk behind others > appears anxious or uncertain > stops walking when approaching or passing by another person/object > complains of feeling off balance particularly to one side > fails to search the environment for information needed > Other:

Eccentric Viewing A form of neuromuscular re-education. Teach patients to develop a new pattern of fixation relative to the object to be viewed. Train to make saccadic and smooth pursuit eye movements using this new direction of gaze.

Eccentric Viewing The direction and magnitude of the eccentric viewing angle are chosen to optimize visual performance when using assistive devices. Must have feedback. With practice and reinforcement, the eccentric viewing becomes natural for the patient.

Eccentric Viewing: Training Procedures Tachistoscope Peripheral Awareness Eccentric Viewing by Dr. G. Goodrich

Tachistoscope Letters/Numbers Variable fond size/speed/number of targets

Peripheral Awareness Quadrants/Zones/ Random Letters/Shapes/Codes Speed Variation Distraction

Eccentric Viewing Exercise Dr. Goodrich

Tracking and Scanning Important for awareness of information in the space. Move around in the space without pump into things. Direct attention to objects in the space for identification, location, and grasping.

Tracking and Scanning Visual Scanning Therapy by Dr. A. Cohen Especially helpful for those with peripheral visual field defect > Hemianopsia with prism > Quadranopsia with/without prism Main goal: efficient scanning in the visual space for easy and safe ambulation.

Tracking and Scanning Visual Scanning Therapy 4-Phase Therapy > Slingshot Phase > 3-Step Scanning Phase > Rear View Mirror Phase > Automaticity Phase

Hemi and stroke

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