New Requirements for Low Vision Rehabilitation Demonstration Billing Note: Please note that MLN Matters article MM5023 contains updated information regarding remittance advice and remark codes and regarding the use of provider identifiers, especially UPINs and the National Provider Identifier. MM5023 is based on CR5023, released on April 28, 2006. To see MM5023, go to http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5023.pdf Provider Types Affected Provider Action Needed
Background
Under this Low Vision Rehabilitation Demonstration, Medicare is extending coverage under Part B for the same rehabilitation services to treat vision impairment that would otherwise be 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. This demonstration will last for five years through March 31, 2011, and is limited to services provided specifically in New Hampshire, New York City (all 5 boroughs), North Carolina, Atlanta, Kansas, and Washington State. Payment for vision rehabilitation services under this demonstration may be made to:
Payment for these services will be made under the physician fee schedule 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 or severe vision impairment that is not correctable by conventional methods or surgery (i.e., cataracts). 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 at least 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 rehabilitation and deriving benefit from such services, and should include:
Rehabilitative services will be conducted within a three-month period of time, in intervals appropriate to the patient’s rehabilitative needs, and will not exceed 36 units of 15 minutes each, or 9 hours total. Rehabilitation 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. All services covered under this demonstration are one-on-one, face-to-face services. Group services will not be covered. Vision rehabilitation services will be furnished in an appropriate setting, including the home of the individual receiving the services, as specified in the plan of care and can be provided by the following:
General supervision means that the physician does not need to be “on premises” nor in the immediate vicinity of the rehabilitation services as would be the case with “incident to” requirements stated in Section 2050 of the Medicare Carriers Manual. Payment for vision rehabilitation services will be made to the qualified physician under the Medicare Physician Fee Schedule (MPFS) or to a facility, including the following:
Occupational therapists in private practice may also submit claims under their own provider number for providing low vision rehabilitation services. However, for occupational therapists in private practice who are participating in the low vision rehabilitation demonstration, claims submitted must contain the same information as on a physician’s claim form and must use the demonstration “G” code for occupational therapists (G9041) for the claim to be considered. Occupational therapists in private practice may not supervise therapy assistants or certified low vision rehabilitation professions, nor may they submit claims for the services of these individuals under the demonstration. Certified vision rehabilitation professionals provide services pursuant to a plan of care and under the general supervision of the qualified physician who develops the plan of care. However, if the certified vision rehabilitation professional has a contractual arrangement with the facility where services are furnished, the facility may submit the bill for services. Payment to practitioners and facilities will be made using the Medicare Physician Fee Schedule (MPFS) with jurisdictional pricing; vision services covered under the demonstration provided in a hospital outpatient setting will not be paid under the OPPS system. Payment for services under this demonstration is limited to low vision rehabilitation. E/M services are not billable under the demonstration. Vision impairment refers to significant vision loss from disease, injury, or degenerative condition that cannot be corrected by conventional means, such as medication or surgery. The impairment must be manifest by one or more of the conditions listed in the following table:
The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnostic codes included in the following table will be used to support medical necessity for coverage under the demonstration.
Most rehabilitation is short-term and intensive, and sessions are generally conducted over a consecutive 90-day period of time with intervals appropriate to the patient’s rehabilitative needs. Patients usually receive therapy one or two times per week, and not less frequently than once every two weeks. The sessions are generally 30-60 minutes in duration. Periodic follow-up and evaluation should be documented by the physician at least every 30 days during the course of the rehabilitation. For the purposes of this demonstration, vision rehabilitation services will not be subject to physical or occupational therapy caps. CMS established four different series of temporary demonstration, or “G,” codes to accommodate rehabilitation services for low vision. Each code series will correspond to the low vision rehabilitation professional that provided the service and will be included in the official instruction issued to your carrier/intermediary. That instruction, CR3816, may be viewed by going to http://www.cms.hhs.gov/Transmittals/2005Trans/List.asp#TopOfPage From that Web page, look for CR3816 and CR 4294, and click on the files for those CRs. Example “G” codes include the following:
Payable Places of Service (POS) for Part B claims include the following:
In addition, facilities that are qualified to submit claims include the following:
Fiscal intermediaries (FIs) will use the claim related condition code 79 to indicate when services are provided outside the facility. When no condition code appears it will indicate that rehabilitation services were provided in the facility. Providers will be required to indicate either no code or code 79 on claims. Facility claims will also use the revenue code 0949 (other rehabilitation services) in addition to the demonstration G-code, which indicates the type of professional who provided the rehabilitation service. This will apply to all institutional settings and CAH outpatient departments. CAHs that elect to use method II billing will use revenue code 0969 or revenue code 0962, whichever is most appropriate. Carriers will accept and process claims from qualified physicians when those claims include:
The plan of care and date can be indicated in Block 19 (Reserved for Local Use) of the CMS-1500. Facilities will use occurrence code 17 for the date the plan of care was established or reviewed. Qualified physicians, occupational therapists, and low vision professionals practicing in designated demonstration areas may provide low vision rehabilitation services to eligible residents of the demonstration areas. Approved demonstration locales are limited to the following; New Hampshire, New York City (all five Boroughs), North Carolina, Atlanta, Kansas, and Washington State. Providers should note that the residence of the beneficiary receiving services and the physician or facility providing the services must be in the same approved demonstration locale (state or metropolitan area) as determined by matching primary residence and primary practice zip codes. Implementation Additional Information You can view the official instruction issued to your carrier/intermediary for complete details regarding this change. That instruction may be viewed by going to http://www.cms.hhs.gov/Transmittals/2005Trans/List.asp#TopOfPage If you have any questions, please contact your carrier/intermediary at their toll-free number, which may be found at http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.pdf Disclaimer MLN Matters Number: MM3816 Revised
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on the CMS Web site. 
on the CMS Web site.
