Article Date: 7/1/2007

Integrate Vision Therapy into Your Practice
vision therapy PART 2

Integrate Vision Therapy into Your Practice

Here are the steps you must take to get your patients, yourself, your office and staff ready to offer this exciting and beneficial specialty.

Barry Tannen, O.D., F.C.O.V.D., F.A.A.O., Hamilton Square, N.J.

In the first installment of this article I discussed the need for vision therapy (VT). Here, in vision therapy part two, I'll discuss fee presentation, the diagnostic and therapeutic equipment needed to get started, VT office design and staff training.

Fee presentation

Once the patient or patient's parent agrees to the discussed VT program, explain your professional fees and office policies. Our VT coordinator (a vision therapist who has some administrative duties) does this by providing the patient with a personalized "VT Patient Agreement" form, which outlines the VT program specifics, health-insurance coverage, scheduling, attendance and payment options.

Before providing this form to the patient, we contact his health-insurance company to inquire about coverage. (Since we normally have at least a week between the VT evaluation and conference, we're typically able to have an answer for patients). I suggest you do the same, as an unresolved health-insurance issue can interfere with the patient getting the help he needs.

Dr. Tannen works with a patient on a standing rotator, which improves pursuit eye movements and eye-hand coordination.

When contacting the health-insurance company, we inquire about the basic CPT code 92065 (vision/orthoptic treatment) for VT sessions. Some health-insurance companies will cover VT for certain conditions, but not others. (See "Common Diagnostic Codes in Vision Therapy," [June OM] in part one for a list of diagnostic codes health-insurance companies often cover).

Some doctors feel that the 92065 procedure code doesn't adequately describe the scope of care we often provide in a VT program. The American Medical Association's (A.M.A.) Current Procedural Terminology (CPT 2007 edition) describes 92065 as follows: "Orthoptic and/or pleoptic training, with continuing medical direction and evaluation."

Necessary VT Equipment
Diagnostic:
  1. +/-2.00D FLIPPERS. Measures accommodative facility.
  2. 12 BASE OUT (BO)/3 BASE IN (BI) HANDHELD PRISM. Measures vergence facility.
  3. FIXATION STICKS. Assess versional and saccadic eye movements.
  4. STOPWATCH. Times the accommodative and vergence facility.
  5. LIGHTHOUSE AND "BROKEN WHEEL" ACUITY CARDS. Assess visual acuity in non-verbal or non-reading patients.
  6. WORTH 4-DOT FLASHLIGHT AND RED/GREEN GLASSES. Used for fusional testing.
  7. STEREOPSIS BOOK WITH POLARIZING GLASSES. Measures depth perception.
  8. MONOCULAR ESTIMATE METHOD (MEM) CARDS. Assesses accommodative lag.
  9. 2.2X TELESCOPES. Assesses an amblyope's visual acuity potential.
  10. MODIFIED THORINGTON TEST CARDS. Determines the natural resting position of the eyes when employed with a transilluminator and a Maddox Rod (see below).
  11. FIXATION DISPARITY CARD. Measures fixation disparity or accommodative lag.
  12. OPAQUE OCCLUDER. Assesses oculomotor deviation behind the occluder.
  13. MADDOX ROD. Reveals and measures phoria or tropia
  14. HORIZONTAL AND VERTICAL PRISM BAR. Measure strabismus and performs free-space vergence ranges
  15. +/-LENS BARS. Estimates refractive status in young or uncooperative patients.
Vergence and anti-suppression training
  1. PEDESTAL MOUNT OPEN STEREOSCOPE. A stereoscope used for the Ann Nichols (AN) and Eccentric Circles (EC) cards (see below).
  2. AN AND EC CARDS. Stereoscopic cards that help train fusion and vergence.
  3. LIGHT BOX TRANSPARENCY VIEWER.
  4. CHEIROSCOPIC ATTACHMENT.
  5. VAN ORDEN (V.O.) TRACING PADS.
  6. CHEIROSCOPIC TRACING PADS.
  7. RED ROCK ATTACHMENT AND CARDS/TILES.

(Numbers three through seven allow patients to perform cheiroscopic, Van Orden tracings and the red rock procedure. All are anti-suppression and eye-hand coordination procedures.)
  • BROCK STRING. Used for anti-suppression training and jump vergence training.
  • VECTOGRAMS. Use four sets: Quoits, Mother Goose, Spirangle and Chicago Skyline to train vergence at various levels of difficulty.
  • DUAL POLACHROME ORTHOPTER. A lightbox specially designed to hold the vectograms.
  • APERTURE RULE CARDS. Help train vergence and accommodation simultaneously.
  • PRISM FLIPPERS. (4-4pd, 6pd, 8pd, 10pd) to vary the difficulty of the vergence training. Use +/-flippers (8: +/-1.00, 1.50, 1.75, 2.00, 2.25, 2.50, +2.50/-3.00, +2.50/-4.00) to vary the difficulty of the accommodative training.
Eye Movement Training
  • STANDING ROTATOR. Trains eye-hand coordination and pursuit eye movement.
  • PEGBOARD ROTATOR WITH PEGS. Helps train eye-hand coordination.
  • STANDARD 2' X 3' CHALKBOARD. Used to train pursuit, saccades and eye-hand coordination.
  • MARSDEN BALL. Develops eye-hand coordination, tracking skills, cognitive abilities, motor planning and bilateral integration.
  • HART CHART. A paper chart with 10 rows and 10 columns of letters to help train saccadic eye movements.
Visual Perceptual Training
  • SMALL AND LARGE PARQUETRY BLOCKS AND PATTERN CARDS. These colored blocks get matched to varying pattern cards, helping to develop figure-ground discrimination, visual memory and eye-hand coordination.
  • VISUAL MEMORY CARDS. Contain numbers, letters and words or shapes that can be used as flash cards to help train visual memory.
  • PEGBOARDS, PEGS AND PEGBOARD DESIGN CARDS. Help train visualization and eye hand coordination.

Therefore, justifying therapeutic activities, such as accommodative, eye movement or visual perceptual therapy under procedure code 92065 may be difficult. You may choose to bill the non-covered VT separately as an unlisted code (CPT 99199). If you do this, clearly explain to the patient that his insurance carrier will most likely not cover these services. Also, have the patient sign an agreement to this effect.

If the patient's health insurance doesn't cover the VT program or the patient cannot afford to pay out-of-pocket per session, we offer two payment options. We do this because we're committed to helping patients if they're committed to getting help.

Setting Up Your VT Room
Here's an example of how you can set up an 8'x12' room with three VT stations that will allow you to work with up to three patients at once. (I used this dimension, as it's typical of many optometrist's exam rooms.)
STEREOSCOPE STATION
  • AN cards
  • EC cards
  • Aperture Rule
DUAL POLACHROME STATION
  • Vectograms

VISUAL PERCEPTUAL/EYE HAND COORDINATION STATION
  • Parquetry blocks
  • Flippers
  • Pegboard activities
  • Visual memory cards
LIGHT BOX (WITH CHEIROSCOPE AND RED-ROCK ATTACHMENT)
  • Cheiroscopic drawings
  • V.O. stars
  • Red-rock technique
STANDING STATION
  • Marsden Ball
  • Brock string
  • Hart chart chalkboard activities

Each sitting station requires 16" × 30" of counter space, with a chair. You can build counters in the room, but you may want to use folding tables first to ensure the design you've chosen works well within the room. A standing station requires a 10' area with an available wall. A computer station that can have random dot stereogram and visual perceptual training programs is optional.

I receive a check from the credit company for the amount of the VT program, minus a finance charge. This charge varies by company and also depends on how many months of interest-free financing I've authorized for the patient (i.e.: six or 12 months). A typical charge is between 7% to 12%.

Other VT practitioners offer a small discount if patients pay for a "block" of therapy sessions, such as eight, 10 or 12 sessions, up-front. Patients can then purchase additional blocks of therapy as necessary. I don't offer this option, as I feel too many options are confusing, and I can usually estimate the entire program length.

Once the VT coordinator has established a payment plan, she discusses the patient's specific weekly schedule for VT therapy and the importance of good attendance. This is so the patient understands that a successful VT program is contingent on his commitment.

Necessary VT equipment

Your VT equipment needs will vary greatly depending on your personal preference, budget and office-space limitations. (See "Necessary VT Equipment," page 52.) The cost for all this diagnostic and therapy equipment is between $2,000 and $2,500. Our typical VT patient averages about $1800 collected (per case) with a profit margin of about 40%. If your income is similar, you might be able to recoup your initial investment after seeing three to four patients.

Many computer-based diagnostic and therapy programs are very helpful, but they significantly add to your start-up cost.

VT room design

It's not absolutely necessary to have a dedicated space for performing VT. In fact, some practitioners use an exam room for VT when they aren't using it for primary care. (See "Setting Up Your VT Room," page 55.)

VT staff

Ideally, you want to train someone who enjoys working closely with patients (especially children), is flexible in approaches to problem-solving and enjoys "thinking on her feet."

We've had good success in recruiting and hiring teachers (especially pre-school) and teacher's aides to work part-time. I've found that these professionals, in particular, are typically available in the late afternoon and early evening (peek times for VT appointments) and seek part-time employment to supplement their income.

To train yourself or staff to perform VT, go to the Web sites of the College of Optometrists in Vision Development (COVD) (www. covd.org) and the Optometric Extension Program (www.oep.org). COVD has an annual meeting that provides education for both practitioners and staff and can help you quickly "ramp-up" your knowledge base to provide VT in your office. Once you have a trained VT tech, she can be a valuable resource in training others.

To gauge whether VT involvement is worth it, practitioners, patients and potential referral sources often ask about the success rates of VT. This varies greatly depending on the condition and the criteria with which you use to define success. Still, many of the success rates (using reasonable criteria) for binocular/accommodative disorders are above 70%. For example, a comprehensive literature review for the efficacy of vision therapy in treating convergence insufficiency showed a combined cure rate of 72%.1 Go to www. covd.org/od/documents/researchandclinicalstudiesonvt.pdf for a summary on the dozens of studies on the efficacy of VT. OM

1. Grisham JD. Visual therapy results for convergence insufficiency: a literature review. Am J Optom Physiol. Opt. 1988 Jun;65(6):448-54.

Dr. Tannen is in a private-group optometric practice in Hamilton Square, N.J., specializing in pediatric care, binocular vision disorders, vision therapy and learning-related vision problems. He is also an associate clinical professor of Optometry at the State University of New York College of Optometry, where he teaches the Vision Therapy course. E-mail him at BTannenOD@aol.com.


Optometric Management, Issue: July 2007