Medicare and Low Vision USA

 

In May of 2002, the Center for Medicare released the following memorandum related to low vision therapy. It applies to therapy provided by optometrists and physicians incident to their services as well as to therapy prescribed by their orders but provided by occupational therapist.

Please note that low vision devices and materials are not covered under Medicare. This clarification is for the therapy only. Also refraction, the measurement of the refractive prescription for eyewear is never covered. Individual states are have policies that determine the extent of examination coverage. The coverage of the examination fees are now being clarified in many states.

                   

CMS Program Memorandum

Medicare Coverage of Rehabilitation Services for Beneficiaries With Vision Impairment

Background

A Medicare beneficiary with vision loss may be eligible for rehabilitation services designed to improve 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 and should be performed by an occupational or physical therapist. (Physical Therapy and Occupational Therapy assistants cannot perform such evaluations.)

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).

Coverage and Limitations

In accordance with established conditions, all rehabilitation services to beneficiaries with a primary vision impairment diagnosis must be provided pursuant to a written treatment plan established by a Medicare physician, and implemented by approved Medicare providers (occupational or physical therapists) or incident to physician services. Some of the following rehabilitation programs/services for beneficiaries with vision impairment may include Medicare covered therapeutic services:

Mobility; Activities of Daily Living; and Other rehabilitation goals that are medically necessary

The patient must have a potential for restoration or improvement of lost functions, and must be expected to improve significantly within a reasonable and generally predictable amount of time. Rehabilitation services are not covered if the patient is unable to cooperate in the treatment program or if clear goals are not definable. Most rehabilitation is short-term and intensive, and maintenance therapy - services required to maintain a level of functioning - are not covered. For example, a person with an ICD-9 diagnosis 369.08 (profound impairment in both eyes, i.e., best corrected visual acuity is less than 20/400 or visual field is 10 degrees or less) would generally be eligible for, and may be provided, rehabilitation services under HCPCS code 97535, (self care/home management training, i.e., activities of daily living, compensatory training, meal preparation, safety procedures, and instruction in the use of adaptive equipment).

Services may be provided by a physician as defined in 1861(r)(1) and (4) of the Social Security Act, a qualified occupational therapist, or a qualified physical therapist. Services furnished by an employee of the physician may only be provided incident to the physician's professional services, must be furnished under the physician's direct personal supervision, and must meet other incident to requirements provided in 2050 of the Medicare Carriers Manual. Certified occupational therapy and physical therapy assistants must perform under the appropriate level of supervision as other therapy services.

Applicable HCPCS Therapeutic Procedures

The following list contains examples which are not meant to limit the provision of other medically necessary services:

ICD-9 Codes for Vision Impairment that Support Medical Necessity

The following are appropriate diagnoses to use for the therapeutic procedures specified above:

BE = Better Eye LE = Lesser Eye

368.41
Scotoma central area

369.12
BE - severe impairment
LE - total impairment

368.45
Generalized contraction or constriction

369.13
BE - severe impairment
LE - near-total impairment

368.46
Homonymous bilateral field defects

369.14
BE - severe impairment
LE - profound impairment

368.47
Heteronymous bilateral field defects

369.16
BE - moderate impairment
LE - total impairment

369.01
BE - total impairment
LE - total impairment

369.17
BE - moderate impairment
LE - near-total impairment

369.03
BE - near-total impairment
LE - total impairment

369.18
BE - moderate impairment
LE - profound impairment

369.04
BE - near-total impairment
LE - near-total impairment

369.22
BE - severe impairment
LE - severe impairment

369.06
BE - profound impairment
LE - total impairment

369.24
BE - moderate impairment
LE - severe impairment

369.07
BE - profound impairment
LE - near-total impairment

369.25
BE - moderate impairment
LE - moderate impairment

369.08
BE - profound impairment
LE - profound impairment

Definition of Levels of Vision Impairment:

 

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