MAB & Low Vision Rehabilitation Demonstration Billing

OCTOBER 23, 2008

Low Vision Rehabilitation Demonstration Billing

Background

The Secretary of the Department of Health and Human Services is directed to carry out and outpatient vision rehabilitation demonstration project as part of the Fiscal Year 2004 appropriations conference report to accompany Public Law HR 2673.  Continuing through March 31, 2011, it is limited to services provided in specific demonstration locales.  These areas are New Hampshire, New York City, North Carolina, Atlanta, Kansas, and Washington State.  This demonstration project will examine the impact of standardized Medicare coverage for vision rehabilitation services provided in the home, office, or clinic, under the general supervision of a physician.  The services may be supplied by the following:

• Physicians;
• Occupational therapists (OT);
• Certified Low Vision Therapists (CLVT);
• Certified Orientation and Mobility Specialists (O&M); and
• Certified Vision Rehabilitation Therapists (CVRT).

Under the terms of this Low Vision Rehabilitation Demonstration, Medicare is extending coverage under Part B for the same rehabilitation services to treat vision impairment that would be otherwise payable when provided by an occupational or physical therapist if they are now provided by a certified vision rehabilitation professional under the general supervision of a qualified physician.  All services covered under this demonstration are one-on-one, face-to-face services.  Group services will not be covered.

Payment

Payment for these services will be made under the Medicare Physician Fee Schedule (MPFS) even when such services are billed by a facility.  They are not subject to bundling under the Outpatient Prospective Payment System (OPPS).  Under this Low Vision Rehabilitation Demonstration, Medicare will cover low vision rehabilitation services to people with a medical diagnosis of moderate to severe vision impairment that is not correctable by conventional medicine of surgical procedure (i.e., cataracts). 

Plan of Care

Services will be provided under an individualized, written plan of care developed by a qualified physician or qualified Occupational Therapist in Private Practice (OTPP) that is reviewed every 30 days by a qualified physician.  The plan of care must attest that vision rehabilitation services are medically necessary and the beneficiary receiving vision rehabilitation is capable of receiving and deriving benefit from such services.  Rehabilitative services will be conducted within a three-month period of time, in intervals deemed appropriate for the patient’s rehabilitative needs, and will not exceed a total of 12 hours.  Typically, patients receive therapeutic sessions once or twice per week and no less than bi-weekly, with each session lasting 30-60 minutes.  Rehabilitative services will be judged completed when the treatment goals have been attained and any subsequent services would be for maintenance of a level of functional ability, or when the patient has demonstrated no progress on two consecutive visits.

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