Take a Second Look at Low
Aging boomers mean that low vision services can be lucrative for your practice.
THOMAS I. PORTER, O.D., F.A.A.O., St. Louis, Mo.
In the United States, vision loss that can't be corrected with glasses, contact lenses or surgery is the third most common ailment affecting individuals over 65 years of age (exceeded only by arthritis and heart disease). An estimated 14 million to 22 million Americans have suffered a vision loss that affects their independence and safety. Because the fastest growing segment of the population in North America is 55 years of age and older, the number of low vision patients will continue to grow rapidly over the next 30 years.
Yet low vision care is a subspecialty that's never been fully embraced by eyecare professionals. The most commonly cited reason for this is economics. Low vision care must make economic sense for practices -- few will enthusiastically provide it if they can use that same chair time more profitably for other areas of eye care. Attention to coding can help surmount this issue.
It's all in the coding
An important misconception among eyecare practitioners is that you must or should complete all the services a low vision patient may require in one visit. Most successful low vision practices, however, take a different approach, spreading services over numerous appointments.
If the patient wasn't referred by another eye doctor or agency, then the first service required is a general ocular health and refractive assessment. The testing performed, the documentation, and the coding used should be much the same as the practice uses for primary care patients. One exception may be the amount you charge for refraction (92015).
Most low vision patients require a more time-consuming and complex refraction in a trial frame -- and you can certainly bill this service at a higher rate. If you determine that a simple change in refraction won't improve the level of functional vision to a satisfactory level, then it may be appropriate to schedule a separate low vision evaluation. It's generally not advisable to include the ocular health assessment and low vision examination in one visit because of the time involved and level of fatigue the patient experiences.
When a patient returns specifically for a low vision evaluation, many practitioners view this visit as a time to evaluate and determine whether low vision aids and visual rehabilitation will improve his functional visual skills. The optometrist sets specific visual goals and investigates solutions. Many code these visits using evaluation and management coding rather than ophthalmic codes. Most specific low vision evaluations involve extensive patient counseling and education, which becomes a determining factor in level of services in the E&M codes. Another common practice is to use the level of vision loss as a primary code in diagnosis and the cause of vision loss becomes a secondary code.
Sometimes another doctor or an agency will send a patient to you for a low vision consultation and evaluation. In this case, the other party has recently performed an ocular health assessment. Several requirements are necessary to bill using consultation codes:
- First, you must have a request for the consultation (document in the patient's record).
- Second, for a visit to qualify as a consultation, you must either give an opinion on a diagnostic unknown or on a mode of treatment that the requesting doctor is not fully familiar with or is unequipped to provide. Low vision services fit nicely into this second category.
- Finally, you must provide a written report to the requesting doctor or agency on the results of the patient visit.
If you determine that low vision aids will help the patient, then you can't use additional professional services codes for dispensing low vision aids on the same day as the consultation.
A note on follow-up visits: Ophthalmic codes generally aren't used for these in low vision practices because of the rigid ophthalmic procedure requirements, as well as the number of visits allowed in a given period. A better option is to continue to bill using E&M codes following appropriate guidelines. And always document face-to-face time as well as the percentage of the visit devoted to patient counseling and education.
Totaling up the Numbers
|Initial Low Vision Evaluation (99244)
Physician involved 60 minutes face-to-face w/patient
|Complex refraction (not covered)
|Initial follow-up visit (99214)
Physician spends 25 minutes face-to-face w/patient
|Second follow-up visit (99211)
Physician doesn't see patient, but is "within shouting distance" as tech/asst.
|Total revenue generated
Don't overlook training
Many primary care practices don't provide extensive low vision rehabilitation training. However, if there's a significant education component involved during the dispensing of low vision aids, then it's legitimate to bill using the E&M code (99210) for the time your technician spends with the patient. You should document this instruction in the patient's record.
Revenue in low vision tools
In many practices, the optical dispensary provides the bulk of the income -- the same is true in low vision practices. Low vision aids also represent a significant revenue source. Much like carpenters' tools, they tend to be one dimensional, so patients often use several. Most established clinics estimate that patients use three to five different aids to achieve their visual goals.
A generally accepted strategy for prescribing low vision aids involves matching a class of aid to the time requirement or duration of the task. For example: a small pocket magnifier for short tasks such as reading a lunch menu and strong reading glasses or an electronic aid for reading lengthy newspaper articles. When formulating a treatment plan for a patient, it's usually best to pick just one or two goals and prescribe devices only for them. At subsequent visits you can address additional goals, which usually require additional low vision aids.
|Low Vision Codes
97112-4 Neuromuscular Re-education (eccentric viewing training and visual scanning training)
Neuromuscular Re-education (gait training, orientation & mobility)
Therapeutic activities (therapeutic activities to improve function)
Training in ADL's (teaching use of devices in activities of daily living
Community re-integration training (teaching use of devices & techniques outside the home)
Visual Performance Testing (reading testing and visual tracking)
Help them with daily living
Many low vision practices include training in the skills that are classified as activities for daily living
(ADL). The ability to bill using these codes is subject to varying state regulations as well as insurance carrier policies. Physical medicine codes 97xxx are typically used in physical therapy but may be appropriate in low vision rehabilitation. Depending on the carrier policy, physician extenders may provide these services according to the regional carrier's supervision rules. States vary as to whether an
O.D. can write orders for these services.
The services are billed in 15- minute units and are limited to six to eight hours of therapy, again depending on regional policies. Documentation is specific for these codes -- it must include such things as a statement in the patient's chart documenting a need for this type of care, a prescription to provider that includes ICD-9 codes, problems that require therapy, potential for benefit and therapy desired.
Strict requirements also exist regarding information that you must communicate to the
provider who orders these services. Include a Plan of Care with assessment, level of impairment, goals, course of action, estimate of time required, frequency of visits and progress notes for each session. Also include a monthly progress report if the patient spends longer than 30 days in treatment, and a discharge summary, signed by a physician/
O.D., indicating to what extent each goal was met. Always check your carrier's billing policies before choosing a treatment modality or method of coding.
Be prepared, be profitable
As the population of the United States continues to age, low vision care represents a tremendous opportunity to provide services that will differentiate your practice from others in your community. To be successful, brush up on clinical skills and research the reimbursement policies for your region.
Dr. Porter is an associate professor in the Department of Ophthalmology at Saint Louis University's Eye Institute in St. Louis, Mo., where he also serves as Director of the Low Vision Service. He is a Diplomate Fellow in the Low Vision Section of the American Academy of Optometry.
Contact him at (314) 577-8258, e-mail firstname.lastname@example.org.
Optometric Management, Issue: July 2003