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Low Vision Services

A SUGGESTED PROTOCOL FOR THIRD PARTY REIMBURSEMENT FOR LOW VISION SERVICES – Medicare based.

By: Randy Jose, OD; Chair, Vision Rehabilitation Task Force

All patients enter with a chief complaint of blurred vision, distortion, field loss, color loss, glare and photophobia, diplopia or fluctuating vision by nature of the low vision.

The first consideration is establishing whether this is a new or established patient. If the patient was seen in an office by another doctor who uses the same tax ID number for billing, then the patient is an “established patient” to the office (tax ID number).

Is this a consultation or office visit. A consultation exists when the patient is referred by another practitioner to you. This referral is best documented as a written referral but you may call that doctors office and confirm the patient’s report that he/she was referred for low vision services.

Document who you talked to in the office and for best documentation ask that person if the referral is noted in their patient record. While not mandated, I ask the patient if they have another scheduled appointment with the referring doctor. If not, then this is probably not a consultation as the referring doctor is no longer managing the patient’s care and is turning the patient over to you. This becomes an initial office visit.

If the patient does have a future appointment, then this can be considered a consultation. The low vision examination is provided and you must write a letter/report back to the referring doctor and a copy must be in your record for complete documentation of a consultation.

Once the decision is made to bill by consultation (99241 – 99245) or see the patient as a new office visit (99201 – 99205), a level of service will need to be established. This can be accomplished by determining the number of pre-specified tests you performed on the patient (review the CPT coding book by AOA) or in Texas we are allowed to bill by the time spent in counseling and education with the patient.

You chose either way based on which is best and most comfortable for you to document. Obviously, the actual level of service you bill depends on the documented testing done or time spent.

I think the counseling and education method best reflects the services we offer in the low vision examination and allows me to better design my testing to meet the patient’s needs instead of the billing needs.

The time approach allows me to more effectively address the morbidity of the ocular disease (or in our terminology, the handicapping impact of the ocular disease) and provides care and prescriptions that will reduce these handicapping effects and improve the patients ability to maintain an independent life style.

I have included a sheet that lists most of the issues that would be typically discussed in a low vision examination. Others can be added as they come up. This can be filled out as you go along through the examination by ticking the areas discussed and noting the time spent in minutes.
The billing is based on the concept that over 50% of the billed time was spent in this type of dialogue. Thus if I tallied up 16 minutes of conversation or face to face time with the patient, this would indicate a documented billing for a level 3 office visit or level 2 consultation.
You are billing for a thirty minute visit of which over 50% (16 minutes) was spent in education and counseling.

Remember, the actual refraction is a separate and non-covered service and is time spent beyond the above mentioned 30 minutes.

You can also use the Comprehensive and Intermediate Ophthalmological codes, 92004 and 92002 for new and 92014 and 92012 for established patients.
There are no set guidelines for these coding categories and thus documentation is more vague. Whether this is good or bad is up to you.
I use these codes when I have no significant medical concerns and the patient is in the clinic regarding a new functional problem related to the ocular pathology that has recently arisen.
I still need to monitor the disease process with acuities, amsler, history and ocular health check but my efforts will be directed to the morbidity or functional loss reported by the patient.
If the patient comes in with the concern of having lost vision in the last few days, this is clearly an office visit.
It is my understanding that a comprehensive visit must include a dilated fundus examination.

If you are going to do some training activities with the patient, the only rehab code that will be reimbursed for Optometrists (or Ophthalmologists) is Activities of Daily Living or Adaptive Instruction (97535). Either the doctor or technician/low vision therapist can provide this service. It is reimbursed for each 15 minute therapy session provided.

In order to bill this service for the same day, the examination code must be followed by the modifier -25.
Thus if you code for an office visit at level three, it would be coded for a new patient as: 99203-25.
This tells medicare that you provided this service today along with another service but the two are independent of one another. In addition you need to document in your record a rehabilitation plan.

Basically this outlines your findings and why you are referring this patient for training and/or further instruction and/or further evaluation related to functional performance of the goal activities of the examination.
A sample is included in the attached examination form. The therapist must fill out a separate examination form outlining the services provided, aids evaluated and make specific note of the tasks evaluated and changes in performance. All these rehab codes are funded based on improvement in performance of disabling activities.

This documentation occurs whether the tech is providing the service or the doctor.

GUIDELINES FOR USE OF LOW VISION MAPS CODES FOR THE PROVISION OF LOW VISION PRESCRIPTIONS AND SERVICES

These guidelines have been prepared to help the counselor and low vision clinician better coordinate the purchase of low vision services and prescriptions for visually impaired consumers of the Texas Commission for the Blind. Both counselor and clinician will be able to use the same order/authorization form to enhance understanding of the new coding process for services and prescriptions.

The effective date for these fees and guidelines is September 1, 2002.

Goals of New MAPS Codes
It is important to understand that the new MAPS coding system was established by the State Legislature to address consistency and sound fiscal practice in determining payments for medical services. It provides an opportunity to create a logical and consistent system for payments for low vision services.
The fees paid are based on the actual cost of devices (based on national catalogs), the costs related to processing the prescription and the professional time spent in designing and dispensing the prescriptive device.
This system will allow the Commission to separate material costs from professional fees, with an emphasis on the professional services offered to consumers.

The Reimbursement System
Devices are reimbursed at cost (based on national catalog price) plus a processing fee. The processing fee is dependent upon the complexity and availability of the device (stock items-25%, microscopes-30%, and bioptics-40%).

Stock Items
There are four subcategories of stock devices (magnifiers, illuminated magnifiers, telescopes and loupes/miscellaneous items). A 25% processing fee is applied when a stock low vision device is ordered through the low vision clinician to cover ordering, mailing and inventory expenses.

A TCB05 fitting fee is allowed per category of device. For example, two handheld magnifiers (non-illuminated) will be authorized for one TCB05. A hand magnifier and an illuminated stand magnifier represent two different categories of devices and thus will be authorized for two TCB05 reimbursements.

In the stock category of devices, the counselor has the option of purchasing devices themselves by doctor prescription (on the authorization request). These devices will still be dispensed in the doctor’s office and the doctor will be reimbursed a fitting fee (TCB05) for the dispensing professional intervention.

Microscopes
Microscopes are any lens representing an add of +4D or greater. These require more time involvement in design and dispensing. A 30% processing fee is provided along with a fitting fee (92354) for professional services involved in dispensing and training.

Bioptics
Bioptics are very complex optical systems. A 40% processing fee is allowed along with a fitting fee (92355) which reimburses for the extended time spent dispensing and training a patient. If two microscopes are approved, there are two fitting fees (92354). Two bioptics requires two fitting fees (92355).

Counselors must obtain all spectacle mounted prescriptive devices through the office of the low vision clinician.

Subsequent evaluation/Patient Monitoring
As indicated earlier, the new MAPS coding system reimburses for prescriptive devices separate from professional services. The evaluation codes are meant to be used for clinical assessments and testing and not for dispensing and training. Thus, the clinician who prescribes a microscope is paid to dispense and train the patient with the 92354 reimbursement.
A subsequent visit can be requested for continued evaluation only if a new functional problem is being addressed. For example, this patient may now need a bioptic for driving or vocational use in college.
This is a new problem area, needing additional evaluations and testing and a TCB04 or TCB05 subsequent visit can be authorized in this case. The clinician must document and justify the need for additional evaluation visits.

The doctor is responsible for monitoring the chronic nature of the ocular pathology at each visit and must take some minimum tests to document stability of the disease process. Thus, when a stock device is prescribed, the authorization should include a brief reevaluation visit (TCB02) along with the device and TCB05 fitting fee.
There is only one TCB02 allowed no matter how many devices are being dispensed.

If stock devices are being dispensed along with a microscope or bioptic, the TCB02 evaluation fee should not be authorized. The 92354 or 92355 reimbursements cover the testing needed for the monitoring of the pathology as part of the dispensing / training process.
Clinicians are strongly encouraged to combine evaluations and low vision recommendations into a single visit whenever possible to assist the Commission in serving the greatest number of consumers within available limited resources.

Remember, the evaluation codes are for evaluating new functional problems and are not to be used for training. The evaluation codes should be requested as follows:

TCB02 (brief evaluation)
TCB03 (intermediate evaluation: for use if additional testing is needed on another vocational or independent living goal)
TCB04 (extended evaluation: for use if additional testing is needed on another vocational or independent living goal).

Order Forms
The following order forms have been developed to help the clinician expedite ordering and putting the order/authorization request in a format consistent with the new MAPS coding system and familiar to the counselor.

Refractive Corrections
Refractive corrections (single vision or bifocals) are reimbursed by V-codes and are listed on a separate page with almost all codes listed for every prescription. There are no processing fees added to non low vision aid Vcodes. TCB05 fitting fee is allowed for dispensing of standard refractive error corrections including bifocals under +4D.

There are conditions under which some optical designs can be reimbursed (tints, hi-index, AR coatings, etc.). The doctor is being requested to provide justification for adding these special parameters to a prescription and document the patient’s need for the add on optics. Specific rules are noted in the form and detailed in the attachment.
In general, progressive adds, trifocals, transition/photochromatic lenses, AR coatings, tints and high index lenses are not considered routine or typical prescriptions for low vision patients and must be justified according the rules established and listed on the attached forms.

If the bifocal is +4D or greater or the single vision reading lens represents a +4D add or greater, the Vcodes are used for the reimbursement of the materials. No processing fee is added.
However, since this is considered a microscope, the clinician should be authorized for a 92354 fitting fee instead of the standard TCB05 fitting fee. In addition, the clinician can request a V2025 deluxe frame reimbursement for this prescription.

Low Vision
There is a separate order form for the categories of low vision prescriptions and a page of special considerations. These should be used as order forms whenever possible to help develop consistency for both counselors and clinicians.

Please feel free to contact Dr. Randy Jose (713 743-1943 or rjose@uh.edu or Ron Lucey, Texas Commission for the Blind MAPS coordinator (512 377-0577 or ron.lucey@tcb.state.tx.us) should you have any questions.