Consider options when coding vision therapy

March 15, 2012

By Harvey Richman, O.D., Third Party Committee

The AOA defines vision therapy as “…a sequence of activities individually prescribed and monitored by the doctor to develop efficient visual skills and processing. It is prescribed after a comprehensive eye examination has been performed and has indicated that vision therapy is an appropriate treatment option. The vision therapy program is based on the results of standardized tests, the needs of the patient and the patient’s signs and symptoms. The use of lenses, prisms, filters, occluders, specialized instruments and computer programs is an integral part of vision therapy” (available at www.aoa.org/x5411.xml).

Various forms of visual therapy have been used for centuries. The concept of vision therapy was introduced in the late 19th century for the non-surgical treatment of strabismus. This early and traditional form of vision therapy is what is now known as ‘orthoptics’- although this term does not limit the work of optometrists and ophthalmologists who today often work beyond the realm of strabismus. This expansion moved vision therapy into the treatment of binocular deficits as well as dysfunctions in visual focusing, perception, tracking and motor skills.

In 1999, the AOA and American Academy of Optometry released their Joint Statement on Vision Therapy. It stated the efficiency of our visual system influences how we collect and process information.

Repetitive demands on the visual system tend to create problems in susceptible individuals. Inefficient vision may cause an individual to slow down, be less accurate, experience excessive fatigue, or make errors. When these types of signs and symptoms appear, the individual’s conscious attention to the visual process is required.

Effective therapy requires visual skills to be developed until they are integrated with other systems and become automatic, enabling individuals to achieve their full potential.

The goals of a prescribed vision therapy treatment regimen are to achieve desired visual outcomes, alleviate the signs and symptoms, meet the patient’s needs and improve the patient’s quality of life. 

It has been suggested that there is a shortage of practitioners who specialize in vision therapy or vision rehabilitation.

It is likely due in some part to the confusing aspects of billing and the low reimbursement from third-party insurances. 

This is complicated by many doctors feeling intimidated by the process of medical billing and coding for all services.

Many doctors feel they are either billing too high, not high enough or at least not getting reimbursed appropriately for what they are providing.

Although there is no single definitive one way to bill vision therapy, as each patient requires different therapy procedures. There are many coding options that can be considered. 

The following are some generally accepted options to use, with combinations of the codes being appropriate when completed and documented correctly.

Special ophthalmological services for vision therapy:

  • 92065 Orthoptic and/or pleoptic training, with continuing medical direction and evaluation.

From an American Medical Association (AMA) Current Procedural Terminology (CPT®) coding perspective, code 92065 would be reported for each individual training session provided by the physician. The physician prescribes exercises to correct ocular problems (e.g., ocular motor misalignment). The physician then trains the patient to perform therapeutic exercises to try to correct the misalignment. There is no specific time allotted to the procedure by CPT. 

  • 92499 Unlisted ophthalmological service or procedure—Physicians may use this code to report services that have not been given a more specific code by CPT. However, insurers are likely to reject claims for services reported with 92499 and/or request further clarification and supporting documentation relative to the services provided.

CPT defines rehabilitation as “a manner of effecting change through the application of clinical skills &/or services that attempt to improve function.”

Physical medicine and rehabilitation codes for vision therapy:

  • 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

The physician or therapist is required to have direct (one-on-one) patient contact.  This does not usually allow for “incident-to” billing. Furthermore, documentation guidelines are very specific and fairly complex as delineated below.

Documentation for provision of vision therapy should be identified in the indications section of the chart. Once established, an individual rehabilitation plan (IRP) must be entered into the patient’s record. Minimum documentation requirements in the IRP and sessions executing the plan are as follows:

1. Patients’ perceptions of visual function and measures of health related quality of life (HRQOL).

2. During execution of the treatment plan, the progress should be documented.

3. Specific goals based upon answers the patient has provided to questions about concerns: for example “to increase reading speed to 100 words per minute.”

4. A description of the method that will be employed to achieve each goal should be in the treatment plan.

5. Quantitative measurements of current performance measurements at each session should be compared to baseline performance measurements. 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.

6. Sufficient time between visits is necessary for patients to apply vision training to their activities of daily living. The vision specialist can assess the patients’ improvement following practice by patients with techniques to maximize performance. This may require periods of at least two to five 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 will be considered by most insurers to be a non-covered benefit, payable by the patient.

8. A written progress report of each session is a required element of Evaluation & Management services and should identify changes in goals, therapy schedules, or treatment plan.

9. Each session using a service whose definition includes specific time requirements, either therapeutic procedures or prolonged services, must have the face-to-face time between the patient and physician or licensed therapist documented to the minute. Units are calculated as described in prolonged services. In the case of therapeutic services, 97530, 97532, and 97533, 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. Three units of therapeutic service require 45 to 60 minutes of face-to-face time.

Evaluation & Management codes for therapy include:

  • 99211 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, five minutes are spent performing or supervising these services.
  • 99212 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a problem-focused history, a problem-focused examination, and straightforward medical decision-making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self-limited or minor. Physicians typically spend 10 minutes face-to-face with the patient and/or family.

Once again, this is not an all-inclusive document or recommendation on how to bill for vision therapy services, but should be used as a primary guidance for doctors that are providing these very important services for their patients. 

It does include what would be provided in most cases of vision therapy provided in an optometric office.

Many other codes, including general ophthalmologic examination, higher-level Evaluation & Management, neurology, otolaryngology and additional physical medicine options, have been suggested and paid for. 

This is concerning because recent third-party audits found a large percentage of doctors not meeting the level of service billed for.

In summary, when it comes to vision therapy or any other service, any CPT code provided by the physician should be considered as an option as long as the documentation supports it.

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