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Editor's Note

Upon occasion it is prudent to publish information about practice management and the administration of behaviorally oriented practices. This Viewpoint article is a type of practice management paper. There are a number of points that should be emphasized to the reader. The opinions are those of the author. The procedure codes that are described here appear to be applicable for the state of Tennessee. Coding policies vary from state to state. Other states may have different codes and each practitioner should investigate, through the state board of optometry, if these codes apply to your state.

The importance of in-depth knowledge of the central nervous system in the practice of optometry is evidenced by the number of hours devoted to the subject in its professional curriculum.1-4 Although these didactic hours emphasize neuro-pathology, this knowledge is particularly helpful in the practice of vision therapy (VT). Optometrists utilize VT procedures to impact these neural networks to eventually improve areas of neural processing.5'9 Optometrists have traditionally documented VT in terms of procedures performed, rather than in the underlying neurological systems being remediated. I propose that we must change our paradigm from thinking of and documenting VT as procedures to one of remediating the underlying neurological dysfunction.

The following chronological history of the changes that took place in my practice represents a case in point. The practice is devoted exclusively to the remediation, by means of VT, of all areas of visual dysfunctions. We traditionally billed the patient and submitted insurance claims, but most frequently received denials of coverage. In the fall of 2005, this pattern was changed. We had applied for prior approval of a VT program for a patient with multiple diagnoses. The primary diagnosis was Duane's syndrome, Type 2 (ICD 378.71).'° The secondary diagnoses were binocular vision dysfunction, unspecified (ICD 368.30) and refractive disorders. We were fully expecting to receive a standard form letter stating that VT was not a covered service under the patient's policy. Much to our surprise, we received a letter stating that the insurance company would pay for 26 VT sessions. They further instructed our office, to use specific CPT9 codes. A copy of the letter is found on page 127.

These approved codes included (See the upper right hand corner of the letter):

97530: Therapeutic activities, direct (one-on-one) patient contact by the provider (use of dynamic activities to improve functional performance), each 15 minutes

92065: Orthoptic and/or pleoptic training, with continuing medical direction and evaluation

97110: Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility

The letter indicated that this insurance company would pay me for these three codes. Further, the insurance company indicated it was paying on the basis of a binocular dysfunction (ICD-368.30) and not the Duane's diagnosis. (See the upper right hand corner of the letter, under service.)

We were aware that these 97000 codes are used by occupational therapists (OT), physical therapists (PT), and speech therapists (SLP). However, it was evident that the insurance company had not limited these codes to OT, PT or SLP. They are classified as neuro-rehabilitation codes. Medicare assigns these codes to OT, PT, and SLP, when ordered by a MD, DO or OD.5 We had never billed these codes for optometric services but were somewhat familiar with them because our office does provide OT services. To assure that we could legally use these codes we sent a copy of the insurance company's letter to the Tennessee State Board of Optometry along with the definition of the 97000 codes and our proposed use of these codes. The State Board of Optometry approved the 97000 codes for use by optometry in Tennessee. These codes are, therefore, within the provisions of the practice of optometry within our state. We began billing these codes with this patient's treatment and were pleased with the promptness and quality of reimbursement. Since this time we have routinely used the 97000 codes with other third party payers and obtained similar results.

THE PARADIGM SHIFT

A paradigm shift for optometric offices offering VT should now occur to match the care being given, neurological rehabilitation. Optometric documentation has traditionally labeled procedures as: "Brock String," "Balance Beam," "Yoked Prism," or some other title. This has been a problem for the reviewers at the major insurance companies. They do not understand what, if any, underlying neurological processes are being impacted by these procedures.

Although we began to receive reimbursements from insurance based upon 97000 codes, these procedures were also new to us, and we sought further confirmation. A former insurance rehabilitation review specialist from a major insurance company was retained. We sent our documentation (type of procedures and amount charged) and asked for an independent opinion. This person, in addition to confirming that the 97000 codes were legitimate charges for optometry, helped us to accomplish our paradigm shift. The shift was from billing for a "procedure" to that of billing for "neurological effect." When an insurance company requests documentation for VT, describe the therapy in terms of neurological function. As an example, a common VT procedure is the Brock String. It is a procedure that is used in most therapy offices today.

The Brock String procedure was previously described for insurance purposes as:

Brock String, performed at 40cm, 1 m, and 2m in several positions of gaze.

We changed the description to:

Stimulation of binocular fusional area and range of motion at multiple points (40cm, 1m and 2m), in multiple positions of gaze with simultaneous awareness of physiological diplopia.

This is a simple change from an emphasis on a procedure to emphasis on the neurological process being impacted. Our office currently documents all procedures in this "neuro-terminology" or, in an affect driven manner, rather than a procedure description. This may be accomplished with any procedure. For example, any procedure that includes balance or movement is now classified as:

vestibular stimulation, vestibular stimulation with (linear, circular, or lateral) motion, or vestibular stimulation in multiple or dynamic positions, or stimulation of vestibular ocular reflex response (if vision is used while balancing).

If the procedure calls for red/green filters, this can documented as:

monocular fixation in a binocular field.

If both the balance activity and the red/ green filter activity are used together, the procedure could be described as:

vestibular stimulation and stimulation of vestibular/ocular reflex while using monocular fixation in a binocular field to increase fusional range of motion in lateral and functional fields (formerly written as R/G glasses on the balance beam).

What is the practical, clinical difference between documenting by procedure and documenting by neurological affect? The answer is, none. One is written for office staff to understand while the other is written for the insurance review and interaction with health care colleagues. This difference in the description is a translation of principles of neurological rehabilitation and biofeedback (VT). These are services that optometrists have been performing for years.

A good reference to assist with the language of neurology is Leigh and Zee's The Neurology of Eye Movements. ." This text, written by two neurologists, describes the processes and neurology for VT. It gives an excellent theoretical base as to how and why VT works. The principles are described in neurological terms. It is my sense that as optometrists we must change our language to describe procedures differently, to improve our communications with other professionals.

Behavioral optometrists understand the neural associations between vestibular, tactile, proprioceptive, auditory systems, and vision. So this "change in paradigm" is not really a change in what we do or how we do it. This change brings optometry into the present and projects us into the future. Correct documentation, coding, and reimbursement are important for successful communication with insurance companies and other professionals. Optometrists, especially the behavioral, the developmental and the rehabilitative optometrists, have always been at the forefront in the understanding of visual functioning, except in the areas of documentation and reimbursement. A change in how we describe what we do should not be difficult to apply. We must, speaking in functional terms, move forward with central focus and peripheral awareness to improve our documentation and coding. The College of Optometrists in Vision Development (COVD) is at the forefront of the American Optometric Association's emphasis toward board certification.12 The COVD certifies competence in the area of VT. Fellows of COVD are board certified specialists, with adequate training and skills to insure the public of competent care. Reimbursement should be at an appropriate specialization level when we are dispensing specialized services.