Coding for orthoptic training

Excerpted from page 48 of the September 2023 edition of AOA Focus. Written by the AOA’s Coding & Reimbursement Committee.

Understanding which codes doctors of optometry should use and their respective definitions is most important in all coding. Doctors of optometry should be aware of CPT updates for 2023. Two code changes implemented in 2023 that impact doctors of optometry were an update to 92065 and the addition of a new code, 92066. CPT codes 92065 and 92066 are now defined as follows:

92065: Orthoptic training; performed by a physician or other qualified health care professional

92066: Orthoptic training; under supervision of a physician or other qualified health care professional

What changed?

The code definitions now distinguish between orthoptic services performed by a physician, such as a doctor of optometry, or qualified health professional (QHP) versus those performed by staff under supervision. Now, orthoptic services provided by clinical staff such as paraoptometrics, vision therapists, certified optometric vision therapists and other nonlicensed employees will only be able to be submitted with the new 92066. For years, no distinction was made based upon the individual who actually performed the therapy session. That differentiation of labor is at the core of valuation of a service using the American Medical Association (AMA) Resource-Based Relative Value Scale system.

Why did it change?

The practice of medicine and the incorporation of new technology into practice constantly changes. That pairs with a CPT code development process that is quite dynamic and subject to yearly review and adjustment. When a new CPT code is created, existing codes are revised, or when a service has been identified as being potentially misvalued, the valuation associated with the code is examined. With the modification of the 92065 definition last year to be simply orthoptic training, the valuation was found not to be in alignment with the current state of the service. This code development led to the realization that some providers performed the service themselves while others simply delegated the complete procedure.

Who can provide services?

In 2013 the AMA established a definition for a QHP in terms of which providers may report services: A “physician or other qualified health care professional” is an individual who is qualified by education, training, licensure/regulation (when applicable), and facility privileging (when applicable) who performs a professional service within his/her scope of practice and independently reports that professional service.” These professionals are distinct from “clinical staff.”

A clinical staff member is a person who works under the supervision of a physician or other qualified health care professional and who is allowed by law, regulation and facility policy to perform or assist in the performance of a specified professional service but who does not individually report that professional service. specialty societies will present the results of these surveys to the RUC. The RUC reviews the validity of the survey results and the societies’ recommended values and then forwards its own recommendation on to the Centers for Medicare & Medicaid Services, which will make the final decision on the value of the services. In this case, the valuations for 92065 and the creation of 92066 were informed by responses to RUC surveys sent to doctors of optometry across the United States. The CMS concurred with the value determined by the RUC, which now appears in the Physician Fee Schedule.

The 2023 Medicare (CMS) conversion factor is $33.06. That number gets multiplied by the total RVU, so for the doctor code 92065, the national average reimbursement will be $40.33 (1.22 x $33.06) per session. The technician code 92066 will have an RVU of 0.77, so the national average reimbursement will be $25.46 (0.77 x $33.06) per session.

All of the CPT codes that doctors of optometry use to describe the services they perform have been through this exact process. Periodically, some of those codes are selected for reexamination based upon a change in utilization or the introduction of new technology. Because change is embedded into this system, it is important that doctors of optometry review the Physician Fee Schedule for their region every year.

For more information, review Vision Therapy and Neuro-Rehabilitation: Optometric Considerations inThird Party Reimbursement.