Low Vision Services (DL32007)
Contractor Information
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Contractor Name Wisconsin Physicians Service Insurance Corporation |
Contractor Number 00951, 00952, 00953, 00954, 52280, 05101, 05201, 05301, 05401, 05102, 05202, 05302, 05402 |
Contractor Type Carrier - FI - MAC |
LCD Information
Document Information
DL32007 LCD Title Low Vision Services Contractor's Determination Number OPHTH-026 AMA CPT/ADA CDT Copyright Statement CPT codes, descriptions and other data only are copyright 2010 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply. |
Primary Geographic Jurisdiction
Oversight Region Original Determination Effective Date Original Determination Ending Date Revision Effective Date Revision Ending Date |
CMS National Coverage Policy
Title XVIII of the Social Security Act, section 1862 (a) (7). This section excludes routine physical examinations.
Title XVIII of the Social Security Act, section 1862 (a) (1) (A). This section allows coverage and payment for only those services that are considered to be medically reasonable and necessary.
Title XVIII of the Social Security Act, section 1862 (a) (20). This section explains outpatient occupational therapy services or outpatient physical therapy services furnished as an incident to a physician's professional services.
Code of Federal Regulations 20 ch 111 Pt. 404 Subpt. P, App1 categorization of impairment of special senses and speech.
Code of Federal Regulations 42 CFR § 410.59 (a) (3) (iii), Restriction of "incident to" therapy (PT and OT) services to be provided by qualified PTs and OTs.
Code of Federal Regulations 42 CFR § 435.530, Definition of blindness
Code of Federal Regulations 42 CFR § 435.531, Determinations of blindness
Program Memorandum (PM) B-98-59 Medicare enrollment of physical therapists in private practice (PTPPs) and occupational therapists in private practice (OTPPs).
PM AB-99-101, CR#1086, dated December 1999 as optometrists may establish and review treatment plan for physical, occupational therapy, and speech pathology services
PM AB-02-078, CR#2083, dated May 29, 2002 for Medicare Coverage of Rehabilitation Services for Beneficiaries with Vision Impairment
Medicare General Information Manual, Pub 100-1, Chapter 5, §70.5 for Physician defined-optometrist
Medicare Benefit Policy Manual, Pub 100-2, Chapter 15, §30.4 for Optometrist's services
Medicare Benefit Policy Manual, Pub 100-2, Chapter 15, §60.1 for incident-to services
Medicare Benefit Policy Manual, Pub 100-2, Chapter 15, §220.2 for physical and occupational therapy provided by physician and physician employees
Medicare Benefit Policy Manual, Pub 100-2, Chapter 15, §230.4 for covered occupational therapy
Medicare Claims Processing Manual, Pub 100-4, Chapter 12, §30.6.15.1 for prolonged services
Medicare Claims Processing Manual, Pub 100-4, Chapter 30, §40.1 for determining whether provider, practitioner, or supplier had knowledge of noncoverage of services
MLN Matters Article, MM 3816 Revised, concerning CR3816
Title XVIII of the Social Security Act, section 1862 (a) (1) (A). This section allows coverage and payment for only those services that are considered to be medically reasonable and necessary.
Title XVIII of the Social Security Act, section 1862 (a) (20). This section explains outpatient occupational therapy services or outpatient physical therapy services furnished as an incident to a physician's professional services.
Code of Federal Regulations 20 ch 111 Pt. 404 Subpt. P, App1 categorization of impairment of special senses and speech.
Code of Federal Regulations 42 CFR § 410.59 (a) (3) (iii), Restriction of "incident to" therapy (PT and OT) services to be provided by qualified PTs and OTs.
Code of Federal Regulations 42 CFR § 435.530, Definition of blindness
Code of Federal Regulations 42 CFR § 435.531, Determinations of blindness
Program Memorandum (PM) B-98-59 Medicare enrollment of physical therapists in private practice (PTPPs) and occupational therapists in private practice (OTPPs).
PM AB-99-101, CR#1086, dated December 1999 as optometrists may establish and review treatment plan for physical, occupational therapy, and speech pathology services
PM AB-02-078, CR#2083, dated May 29, 2002 for Medicare Coverage of Rehabilitation Services for Beneficiaries with Vision Impairment
Medicare General Information Manual, Pub 100-1, Chapter 5, §70.5 for Physician defined-optometrist
Medicare Benefit Policy Manual, Pub 100-2, Chapter 15, §30.4 for Optometrist's services
Medicare Benefit Policy Manual, Pub 100-2, Chapter 15, §60.1 for incident-to services
Medicare Benefit Policy Manual, Pub 100-2, Chapter 15, §220.2 for physical and occupational therapy provided by physician and physician employees
Medicare Benefit Policy Manual, Pub 100-2, Chapter 15, §230.4 for covered occupational therapy
Medicare Claims Processing Manual, Pub 100-4, Chapter 12, §30.6.15.1 for prolonged services
Medicare Claims Processing Manual, Pub 100-4, Chapter 30, §40.1 for determining whether provider, practitioner, or supplier had knowledge of noncoverage of services
MLN Matters Article, MM 3816 Revised, concerning CR3816
Indications and Limitations of Coverage and/or Medical Necessity
Low vision services use aids and education to minimize vision related disability when no restorative process, for example correction of refractive error, corneal transplantation, or cataract surgery is possible.
A Medicare beneficiary with vision loss may be eligible for rehabilitation services designed to improve, restore, and / or compensate for loss of functioning, by therapy, to improve performance of activities of daily living, including self-care and home management skills. Evaluation of the patient's level of functioning in activities of daily living, followed by implementation of a therapeutic plan of care aimed at safe and independent living, is critical. Vision impairment ranging from low vision to total blindness may result from a primary eye diagnosis, such as macular degeneration, retinitis pigmentosa, or glaucoma, or as a condition secondary to another primary diagnosis, such as diabetes mellitus or acquired immune deficiency syndrome (AIDS).
The purpose of rehabilitative therapy is to maximize the use of residual vision and provide patients with many practical adaptations for activities of daily living. Rehabilitation appears to be more effective if it is started as soon as functional visual difficulties are identified.
The level of vision impairment is defined as:
1. Moderate: best corrected visual acuity is less than 20/60
2. Severe (legal blindness)best corrected visual acuity is less than 20/160, or visual field is 20 degrees or less
3. Profound (moderate blindness) best corrected visual acuity is less than 20/400, or visual field is 10 degrees or less
4. Near-total (severe blindness) best corrected visual acuity is less than 20/1000, or visual field is 5 degrees or less
5. Total (total blindness) no light perception.
Loss of central area of detail with macular degeneration, resulting in distortion, (a) and missing segments of words. (b) Magnification of reading material may allow a patient to read.
Indications for Low Vision Service
The criteria for low vision services are met when any of the following categories from CFR 20 Ch 111 are fulfilled:
1. 2.02 Impairment of central visual acuity remaining vision in the better eye after best correction is 20/200 or less.
2. 2.03 Contraction of peripheral visual fields in the better eye
A. to 10 degrees or less from the point of fixation; or
B. so the widest diameter subtends an angle no greater than 20 degrees; or
C. to 20 percent or less of visual efficiency
3. 2.04 Loss of visual efficiency. Visual efficiency of the better eye after best correction 20 percent or less. The percent of remaining visual efficiency equals the product of the percent of remaining central visual efficiency and the percent of remaining visual field efficiency.
Visual efficiency is the product of central visual acuity in the better eye and the visual field efficiency in the better eye. In a phakic or pseudophakic patient with a visual acuity in the better eye corresponding to 6/20, which is 65 percent in the table above if the visual field efficiency equal to or less than 31 percent, the visual efficiency would be 20 percent and the patient would meet criteria 2.04 for low vision services.
Moderate visual impairment, vision less than 20/60, (as defined by the Wilmer Low Vision Services) in association with functional visual impairment, is a qualifying criteria for low vision services when the visual efficiency is > 20 percent. Functional visual impairment is defined as a composite score of 70 or less on the Visual Function Questionnaire (VFQ-25).
This VFQ score of 70 or less should also be established if visual efficiency is > 20 percent. This questionnaire must be retained in the patient's record for review.
The VFQ-25 survey developed by Rand under the sponsorship of the National Eye Institute is an instrument to measure both health related quality of life (HRQOL) and visual function. It is useful in establishing the provider, patient relationship, a treatment plan and identifying goals. Expectations and achievable goals must be explicitly stated based upon responses to concrete questions like those in the VFQ-25 or the following:
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?
If the patient lives confidently with their current visual function visual rehabilitation is not medically necessary. Patients without a perceived need to improve their visual function will not be motivated to learn and practice the complex functions necessary for low vision training.
A Mini-Mental State Examinations score of > 20 must be achieved prior to instituting vision rehabilitation services. If a score of 20 or less is the outcome of the Mini-Mental State Examination, the provider must explain how the patient will retain the new learned material. Furthermore criteria which will provide proof the patient is remembering the new training must be stated in the original treatment plan. For example upon return for each follow up visit the patient will be asked to demonstrate the use of aids and techniques from previous sessions. The demonstration will be undertaken without help or prompting from any other individual. If the patient fails to demonstrate competency on two different occasions the rehabilitation services will be considered to have reached a stable state or plateau and training will be considered maintenance, which is non-covered.
Not all of those reporting a visual disability have a permanent or uncorrectable visual impairment. One purpose of the policy is to establish eligibility criteria for low vision services. A second goal is to define minimum documentation guidelines which will enable a reviewer to determine if goals are relevant to perceived needs of the patient. In addition the policy seeks bright-line determinants of when goals have been achieved or progress has reached a plateau, and treatment is maintenance, which is non-covered by Medicare begins.
Incident To:
A team usually performs low vision services. The responsible physician acts as the diagnostician, treatment planner, and manager. Qualified assistants work incident to the physician to collect information and implement the vision rehabilitation plan.
Incident to provisions apply only when those who assist the managing physician are employees defined in the Medicare Benefit Policy Manual, (Pub.100-2, Chapter 15, §50) and fulfill all the "incident to" requirements. Incident to services are integral but incidental to the physician's services.
The provider must provide documentation that the services provided to a patient receiving low vision rehabilitation meet a basic standard. If the physician or occupational therapist does not provide one-on-one treatment, the individual providing the therapeutic or evaluation and management service at each patient encounter, must identify their credentials which qualify them to provide low vision rehabilitation and sign, or initial their notes.
In addition, a person serving in any capacity incident to a physician must be directly supervised by that physician. For example, a certified technician may not go to a patient's home to collect data incident to a physician unless the physician is there in the residence with the technician.
A Medicare beneficiary with vision loss may be eligible for rehabilitation services designed to improve, restore, and / or compensate for loss of functioning, by therapy, to improve performance of activities of daily living, including self-care and home management skills. Evaluation of the patient's level of functioning in activities of daily living, followed by implementation of a therapeutic plan of care aimed at safe and independent living, is critical. Vision impairment ranging from low vision to total blindness may result from a primary eye diagnosis, such as macular degeneration, retinitis pigmentosa, or glaucoma, or as a condition secondary to another primary diagnosis, such as diabetes mellitus or acquired immune deficiency syndrome (AIDS).
The purpose of rehabilitative therapy is to maximize the use of residual vision and provide patients with many practical adaptations for activities of daily living. Rehabilitation appears to be more effective if it is started as soon as functional visual difficulties are identified.
The level of vision impairment is defined as:
1. Moderate: best corrected visual acuity is less than 20/60
2. Severe (legal blindness)best corrected visual acuity is less than 20/160, or visual field is 20 degrees or less
3. Profound (moderate blindness) best corrected visual acuity is less than 20/400, or visual field is 10 degrees or less
4. Near-total (severe blindness) best corrected visual acuity is less than 20/1000, or visual field is 5 degrees or less
5. Total (total blindness) no light perception.
Loss of central area of detail with macular degeneration, resulting in distortion, (a) and missing segments of words. (b) Magnification of reading material may allow a patient to read.
Indications for Low Vision Service
The criteria for low vision services are met when any of the following categories from CFR 20 Ch 111 are fulfilled:
1. 2.02 Impairment of central visual acuity remaining vision in the better eye after best correction is 20/200 or less.
2. 2.03 Contraction of peripheral visual fields in the better eye
A. to 10 degrees or less from the point of fixation; or
B. so the widest diameter subtends an angle no greater than 20 degrees; or
C. to 20 percent or less of visual efficiency
3. 2.04 Loss of visual efficiency. Visual efficiency of the better eye after best correction 20 percent or less. The percent of remaining visual efficiency equals the product of the percent of remaining central visual efficiency and the percent of remaining visual field efficiency.
Visual efficiency is the product of central visual acuity in the better eye and the visual field efficiency in the better eye. In a phakic or pseudophakic patient with a visual acuity in the better eye corresponding to 6/20, which is 65 percent in the table above if the visual field efficiency equal to or less than 31 percent, the visual efficiency would be 20 percent and the patient would meet criteria 2.04 for low vision services.
Moderate visual impairment, vision less than 20/60, (as defined by the Wilmer Low Vision Services) in association with functional visual impairment, is a qualifying criteria for low vision services when the visual efficiency is > 20 percent. Functional visual impairment is defined as a composite score of 70 or less on the Visual Function Questionnaire (VFQ-25).
This VFQ score of 70 or less should also be established if visual efficiency is > 20 percent. This questionnaire must be retained in the patient's record for review.
The VFQ-25 survey developed by Rand under the sponsorship of the National Eye Institute is an instrument to measure both health related quality of life (HRQOL) and visual function. It is useful in establishing the provider, patient relationship, a treatment plan and identifying goals. Expectations and achievable goals must be explicitly stated based upon responses to concrete questions like those in the VFQ-25 or the following:
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?
If the patient lives confidently with their current visual function visual rehabilitation is not medically necessary. Patients without a perceived need to improve their visual function will not be motivated to learn and practice the complex functions necessary for low vision training.
A Mini-Mental State Examinations score of > 20 must be achieved prior to instituting vision rehabilitation services. If a score of 20 or less is the outcome of the Mini-Mental State Examination, the provider must explain how the patient will retain the new learned material. Furthermore criteria which will provide proof the patient is remembering the new training must be stated in the original treatment plan. For example upon return for each follow up visit the patient will be asked to demonstrate the use of aids and techniques from previous sessions. The demonstration will be undertaken without help or prompting from any other individual. If the patient fails to demonstrate competency on two different occasions the rehabilitation services will be considered to have reached a stable state or plateau and training will be considered maintenance, which is non-covered.
Not all of those reporting a visual disability have a permanent or uncorrectable visual impairment. One purpose of the policy is to establish eligibility criteria for low vision services. A second goal is to define minimum documentation guidelines which will enable a reviewer to determine if goals are relevant to perceived needs of the patient. In addition the policy seeks bright-line determinants of when goals have been achieved or progress has reached a plateau, and treatment is maintenance, which is non-covered by Medicare begins.
Incident To:
A team usually performs low vision services. The responsible physician acts as the diagnostician, treatment planner, and manager. Qualified assistants work incident to the physician to collect information and implement the vision rehabilitation plan.
Incident to provisions apply only when those who assist the managing physician are employees defined in the Medicare Benefit Policy Manual, (Pub.100-2, Chapter 15, §50) and fulfill all the "incident to" requirements. Incident to services are integral but incidental to the physician's services.
The provider must provide documentation that the services provided to a patient receiving low vision rehabilitation meet a basic standard. If the physician or occupational therapist does not provide one-on-one treatment, the individual providing the therapeutic or evaluation and management service at each patient encounter, must identify their credentials which qualify them to provide low vision rehabilitation and sign, or initial their notes.
In addition, a person serving in any capacity incident to a physician must be directly supervised by that physician. For example, a certified technician may not go to a patient's home to collect data incident to a physician unless the physician is there in the residence with the technician.
Coding Information
Bill Type Codes:
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
| 011x | Hospital Inpatient (Including Medicare Part A) |
| 012x | Hospital Inpatient (Medicare Part B only) |
| 013x | Hospital Outpatient |
| 021x | Skilled Nursing - Inpatient (Including Medicare Part A) |
| 022x | Skilled Nursing - Inpatient (Medicare Part B only) |
| 023x | Skilled Nursing - Outpatient |
| 071x | Clinic - Rural Health |
| 073x | Clinic - Freestanding |
| 074x | Clinic - Outpatient Rehabilitation Facility (ORF) |
| 075x | Clinic - Comprehensive Outpatient Rehabilitation Facility (CORF) |
| 077x | Clinic - Federally Qualified Health Center (FQHC) |
| 085x | Critical Access Hospital |
Revenue Codes:
CPT/HCPCS Codes
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.
| 0420 | Physical Therapy - General Classification |
| 0430 | Occupational Therapy - General Classification |
| 0510 | Clinic - General Classification |
| 0519 | Clinic - Other Clinic |
| 92002 - 92004 | OPHTHALMOLOGICAL SERVICES: MEDICAL EXAMINATION AND EVALUATION WITH INITIATION OF DIAGNOSTIC AND TREATMENT PROGRAM; INTERMEDIATE, NEW PATIENT - OPHTHALMOLOGICAL SERVICES: MEDICAL EXAMINATION AND EVALUATION WITH INITIATION OF DIAGNOSTIC AND TREATMENT PROGRAM; COMPREHENSIVE, NEW PATIENT, 1 OR MORE VISITS |
| 92012 | OPHTHALMOLOGICAL SERVICES: MEDICAL EXAMINATION AND EVALUATION, WITH INITIATION OR CONTINUATION OF DIAGNOSTIC AND TREATMENT PROGRAM; INTERMEDIATE, ESTABLISHED PATIENT |
| 92014 | OPHTHALMOLOGICAL SERVICES: MEDICAL EXAMINATION AND EVALUATION, WITH INITIATION OR CONTINUATION OF DIAGNOSTIC AND TREATMENT PROGRAM; COMPREHENSIVE, ESTABLISHED PATIENT, 1 OR MORE VISITS |
| 92081 - 92083 | VISUAL FIELD EXAMINATION, UNILATERAL OR BILATERAL, WITH INTERPRETATION AND REPORT; LIMITED EXAMINATION (EG, TANGENT SCREEN, AUTOPLOT, ARC PERIMETER, OR SINGLE STIMULUS LEVEL AUTOMATED TEST, SUCH AS OCTOPUS 3 OR 7 EQUIVALENT) - VISUAL FIELD EXAMINATION, UNILATERAL OR BILATERAL, WITH INTERPRETATION AND REPORT; EXTENDED EXAMINATION (EG, GOLDMANN VISUAL FIELDS WITH AT LEAST 3 ISOPTERS PLOTTED AND STATIC DETERMINATION WITHIN THE CENTRAL 30¡, OR QUANTITATIVE, AUTOMATED THRESHOLD PERIMETRY, OCTOPUS PROGRAM G-1, 32 OR 42, HUMPHREY VISUAL FIELD ANALYZER FULL THRESHOLD PROGRAMS 30-2, 24-2, OR 30/60-2) |
| 92270 | ELECTRO-OCULOGRAPHY WITH INTERPRETATION AND REPORT |
| 92275 | ELECTRORETINOGRAPHY WITH INTERPRETATION AND REPORT |
| 92283 | COLOR VISION EXAMINATION, EXTENDED, EG, ANOMALOSCOPE OR EQUIVALENT |
| 97003 | OCCUPATIONAL THERAPY EVALUATION |
| 97004 | OCCUPATIONAL THERAPY RE-EVALUATION |
| 97110 | THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY |
| 97112 | THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; NEUROMUSCULAR REEDUCATION OF MOVEMENT, BALANCE, COORDINATION, KINESTHETIC SENSE, POSTURE, AND/OR PROPRIOCEPTION FOR SITTING AND/OR STANDING ACTIVITIES |
| 97116 | THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; GAIT TRAINING (INCLUDES STAIR CLIMBING) |
| 97530 | THERAPEUTIC ACTIVITIES, DIRECT (ONE-ON-ONE) PATIENT CONTACT BY THE PROVIDER (USE OF DYNAMIC ACTIVITIES TO 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 |
| 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 (EG, ACTIVITIES OF DAILY LIVING (ADL) AND COMPENSATORY TRAINING, MEAL PREPARATION, SAFETY PROCEDURES, AND INSTRUCTIONS IN USE OF ASSISTIVE TECHNOLOGY DEVICES/ADAPTIVE EQUIPMENT) DIRECT ONE-ON-ONE CONTACT BY PROVIDER, EACH 15 MINUTES |
| 97537 | COMMUNITY/WORK REINTEGRATION TRAINING (EG, SHOPPING, TRANSPORTATION, MONEY MANAGEMENT, AVOCATIONAL ACTIVITIES AND/OR WORK ENVIRONMENT/ MODIFICATION ANALYSIS, WORK TASK ANALYSIS, USE OF ASSISTIVE TECHNOLOGY DEVICE/ADAPTIVE EQUIPMENT), DIRECT ONE-ON-ONE CONTACT BY PROVIDER, EACH 15 MINUTES |
ICD-9 Codes that Support Medical Necessity
Note: ICD-9 codes must be coded to the highest level of specificity.
| 368.41 | SCOTOMA INVOLVING CENTRAL AREA |
| 368.45 | GENERALIZED VISUAL FIELD CONTRACTION OR CONSTRICTION |
| 368.46 | HOMONYMOUS BILATERAL FIELD DEFECTS |
| 368.47 | HETERONYMOUS BILATERAL FIELD DEFECTS |
| 369.00 | BLINDNESS OF BOTH EYES IMPAIRMENT LEVEL NOT FURTHER SPECIFIED |
| 369.01 | BETTER EYE: TOTAL VISION IMPAIRMENT; LESSER EYE: TOTAL VISION IMPAIRMENT |
| 369.02 | BETTER EYE: NEAR-TOTAL VISION IMPAIRMENT; LESSER EYE: NOT FURTHER SPECIFIED |
| 369.03 | BETTER EYE: NEAR-TOTAL VISION IMPAIRMENT; LESSER EYE: TOTAL VISION IMPAIRMENT |
| 369.04 | BETTER EYE: NEAR-TOTAL VISION IMPAIRMENT; LESSER EYE: NEAR-TOTAL VISION IMPAIRMENT |
| 369.06 | BETTER EYE: PROFOUND VISION IMPAIRMENT; LESSER EYE: TOTAL VISION IMPAIRMENT |
| 369.07 | BETTER EYE: PROFOUND VISION IMPAIRMENT; LESSER EYE: NEAR-TOTAL VISION IMPAIRMENT |
| 369.08 | BETTER EYE: PROFOUND VISION IMPAIRMENT; LESSER EYE: PROFOUND VISION IMPAIRMENT |
| 369.11 | BETTER EYE: SEVERE VISION IMPAIRMENT; LESSER EYE: BLIND NOT FURTHER SPECIFIED |
| 369.12 | BETTER EYE: SEVERE VISION IMPAIRMENT; LESSER EYE: TOTAL VISION IMPAIRMENT |
| 369.13 | BETTER EYE: SEVERE VISION IMPAIRMENT; LESSER EYE: NEAR-TOTAL VISION IMPAIRMENT |
| 369.14 | BETTER EYE: SEVERE VISION IMPAIRMENT; LESSER EYE: PROFOUND VISION IMPAIRMENT |
| 369.16 | BETTER EYE: MODERATE VISION IMPAIRMENT; LESSER EYE: TOTAL VISION IMPAIRMENT |
| 369.17 | BETTER EYE: MODERATE VISION IMPAIRMENT; LESSER EYE: NEAR-TOTAL VISION IMPAIRMENT |
| 369.18 | BETTER EYE: MODERATE VISION IMPAIRMENT; LESSER EYE: PROFOUND VISION IMPAIRMENT |
| 369.22 | BETTER EYE: SEVERE VISION IMPAIRMENT; LESSER EYE: SEVERE VISION IMPAIRMENT |
| 369.24 | BETTER EYE: MODERATE VISION IMPAIRMENT; LESSER EYE: SEVERE VISION IMPAIRMENT |
| 369.25 | BETTER EYE: MODERATE VISION IMPAIRMENT; LESSER EYE: MODERATE VISION IMPAIRMENT |
Diagnoses that Support Medical Necessity
Diagnoses listed in section ICD-9 Codes that Support Medical Necessity
ICD-9 Codes that DO NOT Support Medical Necessity
ICD-9 codes not listed in section ICD-9 Codes that Support Medical Necessity
ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation
Diagnoses that DO NOT Support Medical Necessity
Diagnoses not listed in section ICD-9 Codes that Support Medical Necessity
General Information
Only the criteria defined in the CFA 20 Ch III have historical and administrative precedence as guidelines defining visual disability. Moderate vision loss defined as visual acuity less than 20/60 is considered to be qualifying criteria for low vision services by professionals working in low vision rehabilitation. This must be associated with functional visual impairment.
Physicians knowledgeable about delivering low vision rehabilitation state that cognitive, psychologic, physiologic or other limitations may preclude low vision training. Therefore, in addition to the criteria established in the "Indications Section", a score of 20 or more should be achieved on the Mini-Mental Status Examination to meet initial coverage criteria.
Once coverage criteria for low vision rehabilitation identified in the indications section are established, an individual rehabilitation plan (IRP) must be entered into the patient's record. Minimum documentation requirements in the individual rehabilitation plan (IRP) and sessions executing the plan are as follows:
1. Patient's perceptions of visual function and measures of health related quality of life (HRQOL).
2. (HRQOL) survey for use across conditions including, but not limited to, glaucoma, diabetic retinopathy, and age related macular edema. This questionnaire is suggested as an entrance survey, which would help define the patient's perceived need for vision rehabilitation and design of a treatment plan. During execution of the treatment plan, the same survey could be used to fulfill the requirement that progress be documented. When there is no progress further treatment will be considered a non-covered service.
3. 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.
4. A description of the method, which will be employed to achieve each goal, should be in the treatment plan. For example a patient with 6/20 vision wants to read l (one ) M, normal text print, a 3.5 x magnifier will be tried. A patient with a visual field constricted to 5 o in widest diameter will use a reverse spectacle mounted telescope of 1.8 magnification to increase the field to 9 o.
5. Quantitative measurements of baseline performance should be compared to current performance measurements at each session. 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 previously been taught how to use a magnifier to increase the size of text, but more recent sessions have used Fresnel prisms to enhance the visual field and scanning, 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.
6. 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. This may require five (5) or more days between visits.
7. When there is no progress in a quantitative measurement of performance on two occasions, following the maximal measure of performance, subsequent treatment for that goal will be considered maintenance and is a non-covered benefit. For example, a patient with a restricted visual field has learned to use a large diameter concave lens to locate and avoid objects in a room; CPT codes 97535 and 97537 would no longer be covered. However, there could be a need for additional visual scanning training, CPT code 97112. This would teach the patient to use a typoscope or the more difficult task of reorienting the text to track reading material into a sighted area. In this case additional units of 97112 would be covered.
8. Each session's progress report, part of the E&M service, should identify changes in rehabilitation goals, therapy schedules, or treatment plan.
9. Each session using time dependent codes, either therapeutic procedures or prolonged services, must have the face-to-face time between the patient and physician or therapist documented to the minute. Units are calculated as described in prolonged services. In the case of therapeutic services, 97112, 97530, 97535, and 97537 a minimum of 15 minutes of face-to-face time for each unit of service must be billed. If less than 15 minutes of therapeutic procedure time is involved no therapeutic service may be billed. If less than 30 minutes of a therapeutic service code face-to-face time is recorded only one unit may be billed. If there is less than 45 minutes of face-to-face time for a therapeutic service code provided only 2 units may be billed. Three units of therapeutic service require 45 to 60 minutes of face-to-face time.
Appendices
Physicians knowledgeable about delivering low vision rehabilitation state that cognitive, psychologic, physiologic or other limitations may preclude low vision training. Therefore, in addition to the criteria established in the "Indications Section", a score of 20 or more should be achieved on the Mini-Mental Status Examination to meet initial coverage criteria.
Once coverage criteria for low vision rehabilitation identified in the indications section are established, an individual rehabilitation plan (IRP) must be entered into the patient's record. Minimum documentation requirements in the individual rehabilitation plan (IRP) and sessions executing the plan are as follows:
1. Patient's perceptions of visual function and measures of health related quality of life (HRQOL).
2. (HRQOL) survey for use across conditions including, but not limited to, glaucoma, diabetic retinopathy, and age related macular edema. This questionnaire is suggested as an entrance survey, which would help define the patient's perceived need for vision rehabilitation and design of a treatment plan. During execution of the treatment plan, the same survey could be used to fulfill the requirement that progress be documented. When there is no progress further treatment will be considered a non-covered service.
3. 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.
4. A description of the method, which will be employed to achieve each goal, should be in the treatment plan. For example a patient with 6/20 vision wants to read l (one ) M, normal text print, a 3.5 x magnifier will be tried. A patient with a visual field constricted to 5 o in widest diameter will use a reverse spectacle mounted telescope of 1.8 magnification to increase the field to 9 o.
5. Quantitative measurements of baseline performance should be compared to current performance measurements at each session. 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 previously been taught how to use a magnifier to increase the size of text, but more recent sessions have used Fresnel prisms to enhance the visual field and scanning, 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.
6. 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. This may require five (5) or more days between visits.
7. When there is no progress in a quantitative measurement of performance on two occasions, following the maximal measure of performance, subsequent treatment for that goal will be considered maintenance and is a non-covered benefit. For example, a patient with a restricted visual field has learned to use a large diameter concave lens to locate and avoid objects in a room; CPT codes 97535 and 97537 would no longer be covered. However, there could be a need for additional visual scanning training, CPT code 97112. This would teach the patient to use a typoscope or the more difficult task of reorienting the text to track reading material into a sighted area. In this case additional units of 97112 would be covered.
8. Each session's progress report, part of the E&M service, should identify changes in rehabilitation goals, therapy schedules, or treatment plan.
9. Each session using time dependent codes, either therapeutic procedures or prolonged services, must have the face-to-face time between the patient and physician or therapist documented to the minute. Units are calculated as described in prolonged services. In the case of therapeutic services, 97112, 97530, 97535, and 97537 a minimum of 15 minutes of face-to-face time for each unit of service must be billed. If less than 15 minutes of therapeutic procedure time is involved no therapeutic service may be billed. If less than 30 minutes of a therapeutic service code face-to-face time is recorded only one unit may be billed. If there is less than 45 minutes of face-to-face time for a therapeutic service code provided only 2 units may be billed. Three units of therapeutic service require 45 to 60 minutes of face-to-face time.
In accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice.
See the "Indications and Limitations of Coverage and/or Medical Necessity" section of this LCD for specific utilization parameters.
Additional information related to indications for the use of CPT codes 92081-92083 can be found in the WPS Medicare LCD, Visual Fields, L31348 (OPHTH-054).
Sources of Information and Basis for Decision
See the "Indications and Limitations of Coverage and/or Medical Necessity" section of this LCD for specific utilization parameters.
Additional information related to indications for the use of CPT codes 92081-92083 can be found in the WPS Medicare LCD, Visual Fields, L31348 (OPHTH-054).
Adaptation of retired WPS Medicare J-5 MAC B LCD entitled Low Vision Services (L26679). Original policy retired 01/01/2010.
Highmark LCD; Physical Medicine & Rehabilitation Services, PT and OT
Advisory Committee Meeting Notes
Highmark LCD; Physical Medicine & Rehabilitation Services, PT and OT
Meeting Date:
Wisconsin 05/20/2011
Illinois 05/25/2011
Michigan 05/18/2011
Minnesota 05/19/2011
Iowa, Kansas, Missouri and Nebraska 06/17/2011
Open Meeting: 04/28/2011
*- An asterisk indicates a revision to that section of the policy.
This policy does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the MAC contractor this policy was developed in cooperation with advisory groups which include representatives from various specialties, and adapted for the purpose of converting to MAC jurisdiction.
Start Date of Comment Period
Wisconsin 05/20/2011
Illinois 05/25/2011
Michigan 05/18/2011
Minnesota 05/19/2011
Iowa, Kansas, Missouri and Nebraska 06/17/2011
Open Meeting: 04/28/2011
*- An asterisk indicates a revision to that section of the policy.
This policy does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the MAC contractor this policy was developed in cooperation with advisory groups which include representatives from various specialties, and adapted for the purpose of converting to MAC jurisdiction.
06/17/2011
End Date of Comment Period
08/01/2011
Start Date of Notice Period
04/01/2011
Related Documents
This LCD has no Related Documents.
LCD Attachments
Billing and Coding Guidelines 04/21/2011 (PDF - 15,990 bytes )
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Page Last Updated: Wednesday, 05-Oct-2011 11:49:11 CDT
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