LCD: Low Vision Services L32007
Contractor Information
|
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
L32007 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 2011 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 For services performed on or after 02/15/2012 Original Determination Ending Date Revision Effective Date For services performed on or after 04/01/2012 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. Practice of Physical Therapy, Occupational Therapy, and Speech-Language Pathology
Medicare Benefit Policy Manual, Pub 100-2, Chapter 15, §230.4 for covered occupational therapy
Medicare Benefit Policy Manual, Pub 100-2, Chapter 15, §230.5 for PTA, OTA, €œincident to.€
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
MedLearn Matters Article, MM3816 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. Practice of Physical Therapy, Occupational Therapy, and Speech-Language Pathology
Medicare Benefit Policy Manual, Pub 100-2, Chapter 15, §230.4 for covered occupational therapy
Medicare Benefit Policy Manual, Pub 100-2, Chapter 15, §230.5 for PTA, OTA, €œincident to.€
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
MedLearn Matters Article, MM3816 Revised, concerning CR3816
Indications and Limitations of Coverage and/or Medical Necessity
Low
vision services use optical devices and non-optical adaptive equipment,
skill training, environmental adaptations and counseling 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 patients' independence, safety, quality of life and wellbeing for optimizing the use of residual vision, providing practical skills and adaptations for activities of daily living, providing the skills and resources for community participation, and modifying environments to assure safety. 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 a low vision evaluation (L/VE) by a physician is self-reported functional deficit secondary to any level of visual impairment that cannot be resolved by standard glasses, medicine or surgery.
The criteria for rehabilitation therapy for low vision are met when any of the following categories are fulfilled, and functional deficit compromising daily activities has been confirmed and delineated by a low vision evaluation:
1. 369.00-369.25: Impairment of central visual acuity remaining vision in the better eye after best correction is documented at less than 20/60.
2. 368.41: A central scotoma is demonstrated.
3. A visual field reduction is demonstrated, including 368.45 (generalized constriction), 368.46 (homonymous bilateral field constriction), or 368.47 (heteronymous bilateral field constriction).
When a comprehensive low vision evaluation by a physician that confirms and delineates functional deficits compromising daily activities is not available and provided, a score of 70 on the Visual Function Questionnaire (VFQ) is required for rehabilitation therapy.
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:
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.
Providers of Service
A team usually performs low vision services. The responsible physician may be one who diagnoses and treats the disease or may be one who performs the comprehensive low vision evaluation (LVE). In either case, the physician is the treatment planner and manager. Qualified assistants may assist the physician in collecting information such as medical history and performing visual field testing. Rehabilitation therapy to implement the vision rehabilitation plan is provided by occupational therapists.
Incident To:
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, §60) and fulfill all the "incident to" requirements. Incident to services are integral but incidental to the physician's services. This may include history taking as part of the low vision evaluation and performance of peripheral and central visual field testing. Non-occupational therapists may not conduct rehabilitation therapy and any services they provide may not be billed under occupational therapy codes.
A non-occupational therapist, 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 patients' independence, safety, quality of life and wellbeing for optimizing the use of residual vision, providing practical skills and adaptations for activities of daily living, providing the skills and resources for community participation, and modifying environments to assure safety. 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 a low vision evaluation (L/VE) by a physician is self-reported functional deficit secondary to any level of visual impairment that cannot be resolved by standard glasses, medicine or surgery.
The criteria for rehabilitation therapy for low vision are met when any of the following categories are fulfilled, and functional deficit compromising daily activities has been confirmed and delineated by a low vision evaluation:
1. 369.00-369.25: Impairment of central visual acuity remaining vision in the better eye after best correction is documented at less than 20/60.
2. 368.41: A central scotoma is demonstrated.
3. A visual field reduction is demonstrated, including 368.45 (generalized constriction), 368.46 (homonymous bilateral field constriction), or 368.47 (heteronymous bilateral field constriction).
When a comprehensive low vision evaluation by a physician that confirms and delineates functional deficits compromising daily activities is not available and provided, a score of 70 on the Visual Function Questionnaire (VFQ) is required for rehabilitation therapy.
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:
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. Patients with cognitive impairments that impeded their retention are at an even higher risk for falls and injuries, however, and are likely to benefit from environmental adaptations and caregiver training to insure their safety. Occupational therapists are trained to observe for and manage cognitive deficits and based on this knowledge may determine after reasonable attempts that when no progress is made, for any reason, therapy must be terminated.
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?
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.
Providers of Service
A team usually performs low vision services. The responsible physician may be one who diagnoses and treats the disease or may be one who performs the comprehensive low vision evaluation (LVE). In either case, the physician is the treatment planner and manager. Qualified assistants may assist the physician in collecting information such as medical history and performing visual field testing. Rehabilitation therapy to implement the vision rehabilitation plan is provided by occupational therapists.
Incident To:
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, §60) and fulfill all the "incident to" requirements. Incident to services are integral but incidental to the physician's services. This may include history taking as part of the low vision evaluation and performance of peripheral and central visual field testing. Non-occupational therapists may not conduct rehabilitation therapy and any services they provide may not be billed under occupational therapy codes.
A non-occupational therapist, 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 |
Note:
Use of E & M Codes specific for Low Vision Service is discussed in
Billing and Coding Guideline attachment for this LCD.
CPT 99354
is an add-on code and should be used in conjunction with 99203-99215, to
denote a prolonged low vision service of greater than 90 minutes.
| 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) |
| 92250 | FUNDUS PHOTOGRAPHY WITH INTERPRETATION AND REPORT |
| 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 |
| 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 |
| 99201 - 99205 | OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A NEW PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A PROBLEM FOCUSED HISTORY; A PROBLEM FOCUSED EXAMINATION; STRAIGHTFORWARD MEDICAL DECISION MAKING. - OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A NEW PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. |
| 99211 - 99215 | OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, THAT MAY NOT REQUIRE THE PRESENCE OF A PHYSICIAN. USUALLY, THE PRESENTING PROBLEM(S) ARE MINIMAL. TYPICALLY, 5 MINUTES ARE SPENT PERFORMING OR SUPERVISING THESE SERVICES. - OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. |
| 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) |
ICD-9 Codes that Support Medical Necessity
| 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 effective low vision rehabilitation training. Those with cognitive deficits however may benefit from environmental adaptations and caregiver training to insure their safety. Established regulations for occupational therapists already dictate that when no progress is achieved in two consecutive sessions, therapy must be discontinued.
Once coverage criteria for low vision rehabilitation identified in the indications section are established, 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. (2) A patient with poor contrast, a history of tripping and falling and fear of falling wants to walk safely and confidently. Balance will be assessed, contrast and lighting will be optimized, and glare controlled with appropriate filters and window adaptations. Trip hazards will be removed and a cane will be considered.
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.
5. WPS Medicare considers 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 non-covered benefit. Furthermore, as measurements plateau, the patient's services for that particular service should be terminated. Therefore WPS Medicare may require documentation with the medical rationale for continuing LVR when no progress has been made in two consecutive visits.
a. For example, a patient with central and peripheral visual field deficits 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.
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 between the patient and physician or therapist documented to the minute. Units are calculated as described in prolonged services. A description of counting minutes for timed codes in 15 minutes can be found in the Billing and Coding Guidelines for this LCD under header Reporting of Service Units With HCPCS; Counting Minutes for Timed Codes in 15 Minute Unit.
8. A the completion of therapy, a discharge summary shall be included in the chart stating the level of progress at discharge.
Physicians knowledgeable about delivering low vision rehabilitation state that cognitive, psychologic, physiologic or other limitations may preclude effective low vision rehabilitation training. Those with cognitive deficits however may benefit from environmental adaptations and caregiver training to insure their safety. Established regulations for occupational therapists already dictate that when no progress is achieved in two consecutive sessions, therapy must be discontinued.
Once coverage criteria for low vision rehabilitation identified in the indications section are established, 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. (2) A patient with poor contrast, a history of tripping and falling and fear of falling wants to walk safely and confidently. Balance will be assessed, contrast and lighting will be optimized, and glare controlled with appropriate filters and window adaptations. Trip hazards will be removed and a cane will be considered.
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.
5. WPS Medicare considers 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 non-covered benefit. Furthermore, as measurements plateau, the patient's services for that particular service should be terminated. Therefore WPS Medicare may require documentation with the medical rationale for continuing LVR when no progress has been made in two consecutive visits.
a. For example, a patient with central and peripheral visual field deficits 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.
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 between the patient and physician or therapist documented to the minute. Units are calculated as described in prolonged services. A description of counting minutes for timed codes in 15 minutes can be found in the Billing and Coding Guidelines for this LCD under header Reporting of Service Units With HCPCS; Counting Minutes for Timed Codes in 15 Minute Unit.
8. A the completion of therapy, a discharge summary shall be included in the chart stating the level of progress at discharge.
Appendices
Utilization Guidelines
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).
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
Adaptation of
retired WPS Medicare J-5 MAC B LCD entitled Low Vision Services
(L26679). Original policy retired 01/01/2010.
Comprehensive 2011 CAC review and summary
National Eye Institute (n.d.) What you should know about low vision. Retrieved February 17, 2011, from http://www.nei.nih.gov/health/lowvision/LowVisPatBro2.pdf
Other Medicare Contractor's Local Coverage Determinations including Highmark LCD; Physical Medicine & Rehabilitation Services, PT and OT
Comprehensive 2011 CAC review and summary
National Eye Institute (n.d.) What you should know about low vision. Retrieved February 17, 2011, from http://www.nei.nih.gov/health/lowvision/LowVisPatBro2.pdf
Other Medicare Contractor's Local Coverage Determinations including Highmark LCD; Physical Medicine & Rehabilitation Services, PT and OT
Advisory Committee Meeting Notes
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.
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
06/17/2011
End Date of Comment Period
08/01/2011
Start Date of Notice Period
01/01/2012
Revision History Number
X
Revision History Explanation
04/01/2012:
It is the intent of WPS Medicare to assure access to all beneficiaries
in need of low vision services. Therefore, the following revisions have
been made to this LCD.
1. Revised statement found in the Indications for Low Vision Service section that read;
Occupational therapists are trained to observe for and manage cognitive deficits and they work under established regulations that dictate that when no progress is made in two consecutive visits, for any reason, therapy must be terminated.
To now read;
Occupational therapists are trained to observe for and manage cognitive deficits and based on this knowledge may determine after reasonable attempts that when no progress is made, for any reason, therapy must be terminated.
2. Deleted from Documentation Requirements, paragraph number one (1) that referenced FIM.
3 Removed from Documentation Requirements, former paragraph four (4) now paragraph three (3) all references to FIM.
4. Removed from Documentation Requirements, former paragraph five (5) now paragraph four (4) the words "This may require five (5) or more days between visits."
5. Removed for Documentation Requirements, former paragraph six (6) now paragraph five (5) from the first sentence the words "in two consecutive visits." Revised entire paragraph to better emphasize quantitative measurements
Effective 02/15/2012 (one).
1. Revised statement found in the Indications for Low Vision Service section that read;
Occupational therapists are trained to observe for and manage cognitive deficits and they work under established regulations that dictate that when no progress is made in two consecutive visits, for any reason, therapy must be terminated.
To now read;
Occupational therapists are trained to observe for and manage cognitive deficits and based on this knowledge may determine after reasonable attempts that when no progress is made, for any reason, therapy must be terminated.
2. Deleted from Documentation Requirements, paragraph number one (1) that referenced FIM.
3 Removed from Documentation Requirements, former paragraph four (4) now paragraph three (3) all references to FIM.
4. Removed from Documentation Requirements, former paragraph five (5) now paragraph four (4) the words "This may require five (5) or more days between visits."
5. Removed for Documentation Requirements, former paragraph six (6) now paragraph five (5) from the first sentence the words "in two consecutive visits." Revised entire paragraph to better emphasize quantitative measurements
Effective 02/15/2012 (one).
Reason for Change
Narrative Change
Related Documents
This LCD has no Related Documents.
LCD Attachments
Billing & Coding Guideline 01/01/12 (PDF - 22 KB)
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Page Last Updated: Tuesday, 03-Apr-2012 08:54:23 CDT
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