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The patient’s medical
record must justify that the diagnosis information submitted on the claim
accurately reflects the patient’s condition and the medical necessity for
service. A subsequent determination that the medical record is lacking such
justification will result in a retroactive denial under Section
1862(a)(1) and Section 1833(e) of the Social Security
Act.
- Documentation in the chart should specify
the level of visual impairment, and the ability of the patient to
respond to visual rehabilitation services.
- The initial evaluation and treatment plan
should be documented. If the treatment plan is initiated by a
therapist, the plan must be approved and co-signed by a physician with
experience in Low Vision Rehabilitation.
- Underlying conditions or diseases that may
cause Low Vision should be documented if established. Changes in
visual status that may require additional visual rehabilitation should
be documented in the chart.
Once coverage criteria for LOW VISION rehabilitation identified in the
indications section is 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:
· Patient’s perceptions of visual function and measures of health related
quality of life (HRQOL) have begun to be incorporated into ophthalmologic
clinical outcomes. Scientifically designed visual function questionnaires
contain the power to detect changes over time using repeated measures. The
National Eye Institute Visual Function Questionnaire (NEI-VFQ) is such an
instrument. A short version of the NEI-VFQ 51 item form was developed by Rand under the sponsorship of the National Eye
Institute in 1996, this is the NEI-VFQ-25. It may be used as a vision-targeted,
health related quality of life (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.
· 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.
· 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° in widest diameter
will use a reverse spectacle mounted telescope of 1.8 magnification to
increase the field to 9°.
· 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
readprint, which could be read, would not be necessary to record because it
had previously been addressed. The VFQ-25 survey may be used to show
progress when compared to the entrance survey.
· 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.
· When there is no progress in a quantitative measurement of performance on
two occasions following when the maximal measure of performance achieved on
a goal is attained subsequent treatment for that goal will be considered a
non-covered benefit maintenance. 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.
· Each session’s progress report, part of the E&M service, should
identify changes in rehabilitation goals, therapy schedules, or treatment
plan. If sessions are missed due to weather, illness, or other factors
neither in the physician’s nor the patient’s control, these should be noted
in the progress report of the next session. This is to provide review
personnel documentation why the overall treatment plan might need to be
extended beyond six weeks.
· 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.
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· Advisors with expertise
with Visual Rehabilitation have recommended that most patients require 30
or less units of visual rehabilitation at a particular level of visual
function to achieve most goals. Therefore services in excess of 30 units
(of all components of the program) will be denied as not medically
necessary. Exceptions to the 30 unit limitation may RARELY be considered IF
the addtional services are specifically ordered by the referring physician
AND clinical information is submitted which justifies the medical necessity
of the additional services.
· We would expect that individuals
performing Low Vision Rehabilitation are appropriately trained to perform
this service. Individuals, other than licensed physical therapists or
occupational therapists, who perform these services incident to a
physician, should be certified by an organization such as the Joint
Commission of Allied Health Personnel in Ophthalmology or the American
Optometric Association Commission on Paraoptometric Certification.
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