LCD for Vision Rehabilitation for Low Vision Patients (L17673)

 

Contractor Information

Contractor Name 

BlueCross BlueShield of Tennessee (Riverbend Government Benefits Administrator) 

Contractor Number 

00390 

Contractor Type 

FI 

 

LCD Information

LCD ID Number 

L17673 

 

LCD Title 

Vision Rehabilitation for Low Vision Patients 

 

Contractor's Determination Number 

L17673 

 

AMA CPT / ADA CDT Copyright Statement 

CPT codes, descriptions and other data only are copyright 2007 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.  

 

CMS National Coverage Policy 

Social Security Act: Title XVIII, Section 1862 (1)(A). This section states that no Medicare payment shall be made for items or services that “are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.”

Social Security Act: Title XVIII, Section 1862 (a)(7) and 42 Code of Federal Regulations, section 411.15 et. seq. These sections exclude routine physical examinations.

Social Security Act: Title XVIII, Section 1833 (e). This section prohibits Medicare payment for any claim that lacks the necessary documentation to process the claim.

 

 

Primary Geographic Jurisdiction 

New Jersey
Tennessee
 

 

Secondary Geographic Jurisdiction 

Alaska
Alabama
Arkansas
Arizona
California
Colorado
Connecticut
Florida
Georgia
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Michigan
Minnesota
Missouri
Mississippi
North Carolina
North Dakota
Nebraska
New Jersey
New Mexico
Nevada
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
Tennessee
Texas
Utah
Virginia
Vermont
Washington
Wisconsin
West Virginia
Wyoming
 

 

Oversight Region 

Region IV
 

 

 

Original Determination Effective Date 

For services performed on or after 09/30/2004  

 

Original Determination Ending Date 

 

 

Revision Effective Date 

For services performed on or after 11/07/2004  

 

Revision Ending Date 

 

 

Indications and Limitations of Coverage and/or Medical Necessity 

Low Vision Rehabilitation, for the purposes of this policy, does not include services such as vision training intended to address conditions or circumstances unrelated to vision impairment or loss of vision.

Disability definition is based upon Code of Federal Regulations for Medicaid CFR 20 Ch. 111 P. 404 Subpt P. This standard was chosen because of long-standing historical precedent and its objective numerically defined criteria.

Indications for LOW VISION service are met when any of the following categories from CFR 20 Ch 111 are fulfilled:

2.02 Impairment of central visual acuity remaining vision in the better eye after best correction is 20/200 or less

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

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 = the product of the percent of remaining central visual efficiency and the percent of remaining visual field efficiency.

The table below contains the percent central visual efficiency corresponding to central visual acuity notations.

TABLE NO 1 – Percentage of Central Visual Efficiency Corresponding to Central Visual Acuity Notations for Distance in the Phakic and Aphakic Eye (Better Eye)
SEE ATTACHMENT #2

Snellen visual acuity measurements are not as precise as log of the minimal angle of resolution (log MAR) tests or three point vernier acuity tests. The Snellen acuity test has wide gaps between measured central visual acuities. For example, patients with 20/125, 20/160, or 20/200 would all have recorded visual acuities of 20/200 because there are no measurements between 20/100 and 20/200 on most Snellen acuity charts. It is for this reason, use of log MAR visual activity charts should be the norm in centers providing LOW VISION services.

Visual field efficiency is obtained by adding the number of degrees of eight principle meridians of the contracted field and dividing by 500. Below is a diagram which illustrates a visual field contracted to 30 degrees in the temporal and down and out meridians and 20 degrees in the remaining six meridians.

Pt. 404, Subpt. P, App.1

SEE ATTACHMENT #3

Table No. 2 – Chart of Visual Field Showing Percent of Visual Field Efficiency Method of Computing

Percent visual field efficiency is:

6 x 20 percent + 2 x 30 percent = 180

180/500 = 0.36

0.36 x 100 = 36 percent

Visual field efficiency is 36 percent in the example. The visual field efficiency in the better eye is the determinant of 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 psiudophakicpseudophakic 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 defined by the Wilmer LOW VISION Services (Appendix A) 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) (Appendix B).

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 also not be motivated to learn and practice the/she complex functions necessary for LOW VISION training.

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 give an explanation 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 occasion’s the rehabilitation services will be considered to have reached a stable state or plateau and training will be considered maintenance, which is non-covered.

Occupational therapy designed to improve function is considered reasonable and necessary for the treatment of the individual’s illness or injury only where an expectation exists that the therapy will result in a significant practical improvement in the individual’s level of functioning within a reasonable period of time where an individual’s improvement potential is insignificant in relation to the extent and duration of occupational therapy services required to achieve improvement, such services would not be considered reasonable and necessary and thus are not covered. If a valid expectation of improvement exists at the time the occupational therapy program is instituted, the services would be covered even though the expectation may not be realized. However, in such situations the services would be covered only up to the time at which it would have been reasonable to conclude that the patient is not going to improve. Once a patient has reached the point where no further significant practical improvement can be expected, the skills of an occupational therapist will not be required in the carrying out of any activity and/or exercise program required to maintain function at the level to which it has been restored. Consequently, while the services of an occupational therapist in designing a maintenance program and making infrequent but periodic evaluation of its effectiveness would be covered carrying out the program is not considered.

Services rendered to patients who cannot adhere to a rehabilitation treatment plan, have poor rehabilitative potential, are unable to cooperate in the program or where no clear goals are definable, will not be covered. Therapy given after the patient has attained the maximum goals specified in the treatment plan will be denied. 

 

Coverage Topic 

Occupational Therapy
Physical, Occupational, and Speech Therapy
 

 

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.

 

 

 

Revenue 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.

 

99999

Not Applicable

 

 

CPT/HCPCS Codes 

Other physical therapy codes may be appropriate for related services but do not reflect vision rehabilitation services.

97001

PHYSICAL THERAPY EVALUATION

97002

PHYSICAL THERAPY RE-EVALUATION

97003

OCCUPATIONAL THERAPY EVALUATION

97004

OCCUPATIONAL THERAPY RE-EVALUATION

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 

Primary Diagnosis Codes

The following ICD-9 codes should be used when the above services are provided for the purposes of Low Vision Therapy. When these services are provided for other indications, the ICD-9 codes of those other indications should be listed as the primary diagnosis. This policy will therefore be applied to all claims for the listed HCPCS codes in which the primary diagnosis is drawn from the following list.

Other clinical conditions, such as the loss of contrast sensitivity or other visual functions should be included as secondary diagnoses as applicable, particularly if they relate to the primary cause of the visual loss.

368.14

VISUAL DISTORTIONS OF SHAPE AND SIZE

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

369.01

BETTER EYE: TOTAL VISION IMPAIRMENT; LESSER EYE: TOTAL VISION IMPAIRMENT

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

369.12

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 

 

 

ICD-9 Codes that DO NOT Support Medical Necessity 

All ICD-9 Codes not listed under the “ICD-9 Codes That Support Medical Necessity” section of this policy will be denied.

 

 

 

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation 

 

 

Diagnoses that DO NOT Support Medical Necessity 

 

 

General Information

Documentation Requirements 

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. 

 

Appendices 

LINK TO QUESTIONS AND ANSWERS (COMMENTS) ABOUT THIS
POLICY:

Frequently Asked Questions



 

 

Utilization Guidelines 

·  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.

 

 

Sources of Information and Basis for Decision 

 

  • BCBS Kansas Low Vision policy
  • NHIC Policy on Low Vision Services
  • CPT 2002 Standard Edition American Medical Association
  • Physician ICD-9-CM 2002 Medicode; Sixth Edition; St. Anthony Publishing/Medicode 2002 Publications
  • HCPCS Level II Professional 2002; Thirteenth Edition; St. Anthony Publishing/Medicode 2002 Publications
  • Carrier Medical Consultants
  • The California Academy of Ophthalmology
  • California Optometric Association
  • Southern California College of Optometry
  • The Center for the Partially Sighted
  • Other Carrier LMRP’s

 

 

Advisory Committee Meeting Notes 

This policy was developed based on an existing policies currently in use by other contractors. 

 

Start Date of Comment Period 

06/29/2004 

 

End Date of Comment Period 

08/12/2004 

 

Start Date of Notice Period 

08/13/2004 

 

Revision History Number 

L17673b 

 

Revision History Explanation 

11/07/2004 - The description for CPT/HCPCS code 97537 was changed in group 1

10/30/2007 - Frequently Asked Questions restored to Appendices

11/10/2007 - The description for CPT/HCPCS code 97532 was changed in group 1 

 

Reason for Change 

Maintenance (annual review with new changes, formatting, etc.)
 

Last Reviewed On Date 

12/12/2007 

 

Related Documents 

This LCD has no Related Documents.

 

LCD Attachments 

There are no attachments for this LCD

 

Other Versions 

Updated on 11/10/2007 with effective dates 11/07/2004 - N/A

Updated on 10/30/2007 with effective dates 11/07/2004 - N/A

Updated on 09/05/2006 with effective dates 11/07/2004 - N/A

Updated on 11/15/2004 with effective dates 11/07/2004 - N/A

Updated on 11/07/2004 with effective dates 09/30/2004 - N/A

Updated on 10/07/2004 with effective dates 09/30/2004 - N/A