Thinking about low vision in your practice? Start here

Ask Sherry Day, O.D., what she finds most rewarding in low vision care and she doesn’t hesitate.

“Giving hope back to these patients,” says the clinical assistant professor at the University of Michigan Department of Ophthalmology and AOA Vision Rehabilitation Committee member. “Expressing their gratitude toward me, countless patients—from teens to seniors—have asked, ‘why wasn’t I told about you years ago?’ Their new ‘disability’ provides a new opportunity to develop new abilities.”

Almost 3 million Americans, age 40 and older, currently live with low vision, an impairment that can exact an enormous psychosocial and economic toll on patients, their family and society. Easily, patients can spiral into depression at their loss of independence, Dr. Day notes, and that may escalate quickly into a loss of purpose and hope. Fortunately, low vision services offer patients a way to maximize the vision they do have via specialized adaptations or devices.

This February is Low Vision Awareness Month, an important public health observance that serves to educate the millions of Americans with degrees of vision loss about the benefits of vision-rehabilitation services in helping make the most of their sight. With such attention, it’s important to note that optometry plays a leading role in providing low-vision care, often alongside a multidisciplinary care team, yet such services do require a different approach than a routine medical eye exam.

“Eye doctors treat, reduce and halt progression of eye disease but usually stop at that achievement,” Dr. Day says. “While treatment of the eye disease is highly important, care of the patient cannot end there. True, a patient may be stable at 20/100 after injections for exudative AMD, but how does that patient go about their daily activities, such as reading or driving, with 20/100 vision?

“Low-vision rehabilitation addresses the life of the patient.”

In this expanded interview from the January/February 2021 issue of AOA Focus, doctors of optometry share their views on the criticality of low-vision care, how to effectively deliver low-vision and vision-rehabilitation services, and the associated coding considerations.

The practice of low vision: Clinical takeaways

Janis Winters, O.D., an associate professor at Illinois College of Optometry who practices in both the primary care and low-vision clinics, offers five ways that doctors of optometry can incorporate low-vision and rehabilitation services into their practices. 

1. Determine who would benefit from vision rehabilitation.
   Use a broad definition of visual impairment. I don’t link assessment of visual impairment strictly to a certain visual acuity standard. Any patient with disease that impacts functional vision could possibly benefit from low-vision services. Some of the best outcomes occur if assistance is provided when the condition is minor, or function slightly affected; waiting until the condition is severe can make rehabilitation difficult with outcomes not meeting expectations.
   
2. Get a complete patient history.
   This could take the form of a few targeted questions, e.g., asking a patient who complains of blur at near, “How do you position yourself and the lighting when you read?” can lead to a better understanding of how to proceed with the examination. Another option is standardized questioning that is self-administered or by staff to provide additional history.
   
   
3. Functional vision testing can aid in defining vision loss.
   Contrast sensitivity, color vision, visual field and glare testing—these tests can lead to a better understanding of vision beyond visual acuity and give direction for what would best assist a patient in meeting their visual goals. Code and bill appropriately for this testing and recommendations made based upon the testing.
   
   
4. Low vision isn’t just microscopes and magnifiers.
   While traditional devices and filters still play an important role, technology has provided us with more tools to help our patients. Desktop and portable electronic magnifiers have been developed specifically to assist visually impaired individuals. With traditional magnification devices, such as a handheld or stand magnifier, lens size decreases when power of device is increased, which impacts the field of view. This is not the case for electronic magnification. Reversing the polarity of text can make a great difference in fluency and ease of reading for a patient, while even smart phones or computers contain accessibility features to enhance text.
   
   
5. Consider collaboration.
   What levels/types of visual impairment are you comfortable managing and what is best for your practice type? Seek out additional education or a mentor, and if a case is beyond your desired level, refer either inter- or intra-professionally. Consider intra-professional referral with behavioral or developmental optometrists, neuro-optometric rehabilitation optometrists, contact lens specialists or other specialties; or, consider inter-professional referral with occupational therapists, physical therapists, orientation and mobility specialists, etc. Communication between professionals and the patient can be the key to success.

Toward that last point, Dr. Day adds that low-vision services are most effective when provided in a team setting: doctors of optometry, occupational therapists, orientation and mobility specialists, social workers and other health care providers.

“Doctors of optometry and ophthalmologists are the main referral source; however, with increased knowledge of low-vision services, I’ve had referrals come directly from other medical specialties, such as neurology,” she says.

Doctors of optometry perform the low-vision evaluation, including optical testing and prescribing of devices to enhance specific functional tasks, e.g., an artist needing to see her canvas to paint. A referral to the orientation and mobility specialist may teach the patient to navigate and mobilize with a cane, Dr. Day says, while a social worker can assist with the logistics and emotional well-being of a patient being trained to regain independence with low-vision rehabilitation.

“We all play a separate but vital role in enhancing the lives of the low-vision patient and thus their families, too,” she adds.

Coding for low vision: How E/M coding changes affect services

What’s more, there are specific coding concerns related to the furnishing of low-vision services that doctors of optometry need to know—and substantial changes that took effect in 2021, namely, changes to the coding and documentation for the evaluation and management (E/M) services.

The E/M code category in the Current Procedural Terminology (CPT) code set describes a certain set of patient visits, and starting this year, those codes will need to be selected based on what is more appropriate: medical decision-making or total time, as opposed to a patient’s history and physical findings. As AOA’s Coding Experts noted in the November/December 2020 edition of AOA Focus, total time was previously reportable by itself but only if more than 50% of time with the patient is for coordination of care or counseling; however, the new system permits total examination time by the doctor qualifying on its own.

As Harvey Richman, O.D., AOA’s alternate adviser to the CPT Editorial Panel and a vision-rehabilitation-focused doctor himself, explains, these changes have immediate implications for low-vision services. Considering low-vision doctors spend an exceptional amount of time with patients as opposed to a traditional medical visit, time will most likely be greater utilized. That said, it is important to note that usage of the prolonged service modifier also has changed.

“Previously, a doctor might do a lower-level E/M service and then add prolonged service modifiers to it, but at this point you must reach the highest level of E/M before you can add the prolonged service code to it,” Dr. Richman explains.

There is some confusion as CPT’s set time base for Level 5 differs from that settled upon by the Centers for Medicare & Medicaid Services (CMS). Multiple prolonged services codes were condensed into a single code billed at 15-minute increments when time exceeds a Level 5 visit; however, the CMS says prolonged services may only be billed when the maximum time for a Level 5 visit is exceeded by 15 minutes or more, rather than the minimum time.

Additionally, it is important to understand that if practitioners are using paraoptometric staff or billing for diagnostic services during the visit, that time is to be withdrawn from what is provided to the patient during the evaluation and management. In other words, if a patient’s hour-long visit includes five minutes of pre-testing, a 10-minute refraction and 10-minute visual field, Dr. Richman says, then the doctor is technically spending only 35 minutes with the patient.

Dr. Richman adds that from a medical decision-making standpoint, it also is important to obtain and review as many of the previous doctors’ reports into the chart because they count as data points.

Low-vision specialist Maria Richman, O.D., expands upon the previous points that the more extensive low-vision and vision-rehabilitation services these types of practices offer naturally result in a higher level of coding, but greater education of these services will open opportunities for more optometry practices to adopt these services.

“There are many primary care doctors who offer low-vision services to a level that they’re comfortable with and still be able to use these codes,” Dr. Maria Richman says. “In the past, low vision was seen as a service that took up a lot of time and did not have appropriate codes to reflect the work. Now, those practices looking to expand their services have coding options to reach a broader patient base.”

Separately, all doctors and other qualifying health care providers participating in the Merit-based Incentive Payment System (MIPS) should be aware that the AOA successfully advocated for an Improvement Activity (IA) related to low vision that the CMS finalized for 2021. Acknowledging that some low-vision patients are not aware of the services available to them, the AOA proposed this IA to encourage other doctors to utilize AOA or National Eye Institute materials to educate and refer patients for appropriate vision-rehabilitative care.

Doctors who perform this activity (IA_AHE_7) under the Quality Improvement Program for 2021 would have to attest to their performance of the activity during the 2021 attestation period.

To find a colleague who provides vision rehabilitation care, visit the AOA doctor locator and select the “low vision” specialty area.

Are you interested in helping the AOA advocate for better vision-rehabilitation policies, regulations and laws? Joining the AOA's Vision Rehab Advocacy Network will not only keep you updated on the AOA's vision-rehabilitation advocacy efforts and resources but also help the AOA identify opportunities for you to get involved in promoting vision rehabilitation on local, state and federal levels.