Introducing LVR into Treatment Settings

1
Introducing LVR into Treatment Settings
2
Lecture Objectives

• Understands current status of LVR in healthcare
• Understands components of low vision rehab
  programs

3
Treatment Settings

• There are no specific restrictions on provision
  of OT services
• Can be provided in all treatment settings/models
• Generally if OT is covered, LVR will be covered
• HMOs are an exception
• Most programs are outpatient based and provide
  treatment through the healthcare system

4

• Most programs provide at least some treatment in
  the home
• Deviation from traditional hospital based
  programs
• More appropriate for this population
• Environmental modification critical to
  independence and safety
• Patients have significant transportation issues
• But more expensive for hospitals to provide
• Cant bill for travel time
• Requires one to one treatment
• Will not see for profits provide this aspect
• Creates some billing challenges
• Must be billed as Medicare Part B while hospitals
  traditionally bill all rehab as part A
• Requires careful attention to paperwork to ensure
  billed properly

5

• Most referrals come from ophthalmologists
• Most programs use ophthalmologist as the medical
  director
• Although significantly more optometrists
  specialize in low vision, insurance is structured
  for MD referral
• MD referral guaranteed in all states but
  optometry is not
• Older adults make up the majority of referrals
  for all programs
• OTs niche in low vision rehab
• Many programs ONLY see older adults
• Pediatrics is more difficult to provide
• Services are already in place through school
  systems
• Reimbursement is less stable

6

• Predominance of older adults puts LV programs at
  the mercy of Medicare
• A good thing and a bad thing
• Guarantees reimbursement
• Which can be lost at the wim of Congress
• Balance Budget Act of 1998
• Many programs combine brain injury and low vision
• Brain injury causes low vision
• Changes in acuity, field and oculomotor control
• Persons with brain injury can also have low
  vision as a secondary condition

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Other Settings

• Home health agencies
• Must have homebound status to bill Med A
• Agency needs to have capacity to bill Med B
• Private Practice
• OT has independent provider status with Medicare
• Obtain individual provider number
• May organize a practice with several OTs
• Must work independently of physicians
• Limited in billing to 1500 per calendar year
• Greater risk but also greater control

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• Member of physician practice
• If billing under physicians provider number,
  cannot not do home visits
• May have own provider number and assign Medicare
  benefits (payments) and work as an employee of
  the practice
• CORF
• Capable of billing Medicare Part B
• Can provide in home and in clinic services
• Must meet Medicare CORF regulations
• Blind Rehab System
• Private agencies, the VA
• Work as a low vision specialist

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Referral Base

• Physicians
• Primary Ophthalmologists
• Retinal specialists
• Glaucoma specialists
• Neuro-ophthalmology specialists
• General practitioners
• Secondary
• Family practice physicians and internists
• Gerontologists
• Sometimes
• Endocrinologists
• Neurologists
• Physiatrists

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Referral Base

• Others
• Low vision optometrists
• Opticians
• State vocational rehabilitation services
• Other therapists in the community
• Service coordinators for area services for older
  adults
• Activity directors of residential facilities for
  older adults

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Medicare Reimbursement Structure
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History of Medicare Reimbursement

• 1991-HCFA under petitioning from Dr Donald
  Fletcher acknowledged low vision as a physical
  impairment
• But did not implement guidelines or change
  wording of Medicare documents
• Permitted ophthalmologists and optometrists to
  bill for low vision exam
• Permitted referral to licensed health care
  providers for rehabilitation, excluded
  traditional providers
• First outpatient programs using OT were begun
• OTs entry is just 10 years old

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• 1991-2002 Without a national policy, payment for
  LVR depended on wims of regional Fiscal
  Intermediaries
• Coverage varied from region to region
• Power of FIs varied depending on which party was
  in power dems or republicans
• Programs had to work with the FI in their state
  to ensure coverage
• 22 regional FIs established coverage guidelines
• Some very restrictive

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• May 29, 2002 CMS issued a program memorandum to
  all FI and carriers detailing coverage of
  rehabilitation services for persons with low
  vision
• Medicare beneficiaries who are blind or visually
  impaired are eligible for physician prescribed
  rehabilitation services from approved health care
  professionals on the same basis as beneficiaries
  with other medical conditions that result in
  reduced physical functioning

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• Memorandum specified conditions for coverage
• Specific set of ICD 9 codes
• Suggested CPT codes
• Placed low vision squarely in line with standard
  PMR requirements for OT
• Must have physician referral
• Certification if initial plan of care
• 30 or 60 recertification
• Documentation must be completed according to PMR
  requirements

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Legislation Impacting Low Vision Rehab Services

• OT entry into field has made traditional
  providers very nervous
• David vs. Goliath turf issues
• Two approaches taken
• If you cant beat em join em
• Many traditional provided sought CORF status and
  hired OTs to provide services
• Fight em off anyway you can
• Publicly question OT competency
• Tried to correct their own deficiencies by
  instituting Low Vision Therapist Certification

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• Tried to enact legislation that would exclude OT
  from providing services
• Original HR 2870 Vision Rehabilitation Coverage
  Act of 1998
• sponsored by Rep Capuano who was unaware that OT
  provided LVR
• Would have excluded OT from providing services by
  separating LVR from PMR and creating a separate
  system using traditional providers but billing
  Medicare
• Immediately opposed by AOTA, AAO and AOA
• If you think AOTA doesnt do anything for
  you-think again and pay those dues!!
• Forced a rewrite of the bill

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• Revised HR 2484 reintroduced in July 2001,
• New bill left OT intact and laid out provisions
  for coverage of services by OM specialists and
  rehab teachers
• AOTA, AAO, AOA support the bill
• Bill has been in committee since shortly after
  9/11
• Summer 2003
• Version of the bill (S1967) introduced into the
  Senate
• Attached to the Medicare Prescription bill
• Still in committee for reconciliation

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• Optometry legislation
• Traditionally Medicare only permitted MD referral
• Congress passed a technical amendment attached to
  the BBRA of 1999
• Specified that an optometrist meets the
  physician supervision requirement for outpatient
  rehabilitation services (HR 3075, section 221)
• Allows optometry to refer patients with low
  vision to licensed health care providers
• And to certify and re-certify therapy plans of
  care
• CMS officially authorized optometry referral in
  the May 2002 memorandum
• Despite federal legislation, not all state
  licensure acts permit optometry referral
• New York, W.Virginia,Pennsylvania, Washington

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Competency Issues and the Politics of Low Vision

• Dont expect to be embraced by traditional
  providers
• Your qualifications will be examined and must be
  good
• OT credentialing is enough for Medicare but not
  sufficient for other providers
• Must demonstrate that you have additional
  training
• This curriculum
• Continuing education venues
• Courses
• AOTA self study
• Some OTs obtain certification as Low Vision
  Therapist through ACVREP (www.acvrep.org)

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Key Issues in Competency

• Remember you work as a member of team
• Do not overstep your expertise or scope of
  practice
• OTs do not have expertise in outdoor mobility,
  Braille, psychological counseling, meal planning
  for diabetes,optical prescription etc.
• Seek referral to appropriate service providers
• State vocational rehab services
• State blind agency or program specializing in
  aspects of low vision

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Working with other LVR professionals

• Difficult at the moment to network with O/M and
  RT because we work in separate systems
• Qualifying criteria (legal blindness) for
  blindness system services precludes many of our
  patients
• Documentation and treatment approach are
  different
• However that doesnt mean we should exceed our
  competency level and try to provide all services

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Working with others

• Important to respect the skills/perspective of
  other professionals
• Different points of view strengthen the treatment
  intervention
• Be knowledgeable about the services they can
  provide to your clients
• Types of services
• Qualifying criteria
• Referral process

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OT Resources

• AOTA Clinical Self Paced Study
• Warren M (Ed) (2000).Low Vision Occupational
• Therapy Intervention with the Older Adult,
  Bethesda
• MD American Occupational Therapy Association
• AOTA Guidelines
• Warren, M. (1998). Occupational therapy practice
  guidelines for adults with low vision Washington
  D.CAmerican Occupational Therapy Association.
• October 1995 American Journal of Occupational
  Therapy
• Special issue on low vision rehabilitation

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Other Resources

• Vision Enhancement
• Vision world wide Inc www.visionww.org
• Association for Education and Rehabilitation of
  Blind and Visually Impaired (AER)
• www.aerbvi.org

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Additional Resources

• AER Approved Graduate Programs in Orientation and
  Mobility
• Western Michigan University
• Florida State University
• San Francisco State University
• California State University Los Angeles
• University of Pittsburgh
• University of Northern Colorado
• University of Arkansas
• Michigan State University
• Texas Tech University
• Northern Illinois University
• University of Texas at Austin
• Pennsylvania College of Optometry
• University of Massachusetts at Boston