R Venkataramanan

R Venkataramanan

R Venkat's Blog

R Venkat's Blog
"To be an Inspiring Teacher,one should be a Disciplined Student throughout Life" - Venkataramanan Ramasethu



Sunday, September 1, 2013

Low Vision Rehab Myths

Low Vision Rehab Myths

Seven primary myths regarding this specialty are costing patients and practitioners.

Sarah Hinkley, O.D., F.C.O.V.D., Big Rapids, Mich.

On the Discovery Channel series MythBusters, a team of science enthusiasts set out to test the validity of various Myths accepted as truth. For instance, it has been said that placing a silver spoon in an open champagne bottle will keep the sweet beverage bubbly. This and 424 other myths, out of 769—roughly 55%—have been “busted” since the shows debut nine years ago.

In informally asking fellow optometrists and former students, many of whom have completed residencies in low vision rehabilitation, why they don't provide low vision rehabilitation services, the answers I've received are saturated with common myths about this specialty.

Here, I list these myths, and in the words of the MythBusters team, I “bust” them.

1 “Plenty of O.D.s provide low vision services”

In fact, there are very few. Although exact estimates are difficult to obtain, in Michigan, an estimated 586,499 people in the 40+ age group alone have some type of visual impairment.1,2 Yet, of the approximately 1,600 optometrists, only 50 Michigan Optometric Association member optometrists say they provide low vision rehabilitation services.3,4 In speaking with low vision rehabilitation service providers in other states, they provide similar statistics. The consensus is that rural areas are the most underserved, probably because travel to metropolitan areas for care is often required and is largely complicated by the inability of these patients to drive themselves to appointments.

In addition, current low vision rehabilitation practitioner shortages are expected to worsen as the prevalence of age-related eye disease-causing visual impairment is estimated to double in the next three decades.5 In fact, between 1985 and 2050, the number of Americans 55 and older will increase by 113%, compared with a 33% increase in the general population, as estimated by the U.S. Census Bureau.6 This means there will be an even greater need in the foreseeable future for low vision rehabilitation services. Translation: There has never been a better time to expand your practice by providing low vision rehabilitation.

2 “Low Vision isn't stimulating”

I'll be the first to admit that learning and working with the necessary devices and lighting to provide low vision rehabilitation services is not always exciting, but this is only one aspect of the low vision rehabilitation practice. What many optometrists fail to remember is that patients who have visual impairment also have pathology. Therefore, those O.D.s who provide low vision rehabilitation are not sacrificing the excitement or challenge of ocular and systemic disease management. In actuality, these O.D.s are playing a crucial role in this management.

For example, if a diabetic retinopathy patient whom the low vision rehabilitation provider has been examining presents with a sudden change in visual acuity, contrast sensitivity, etc., it is under his or her jurisdiction to determine the reason(s), and this requires using various diagnostic tests to evaluate pathology. In fact, managing the vision rehabilitative needs of patients who have diabetes is one common example of the importance of the low vision rehabilitation optometrist on the patient's healthcare team.7

In addition, the opportunity arises for low vision rehabilitation providers to become involved in cutting-edge research through practice involvement or patient referrals for research trials.

The bottom line is that I have learned more about ocular and systemic disease in one month of low vision practice than in three years of primary care practice.

3 “I don't want to treat just geriatric patients”

The rising prevalence of agerelated eye diseases, such as agerelated macular degeneration, may lead some optometrists to erroneously think that low vision rehabilitation is solely comprised of geriatric patients. (See “The Senior Stereotype,” below.) However, visual impairment does not discriminate based on age.

For example, Stargardt's Disease alone affects 30,000 to 50,000 Americans and most commonly presents in the teenage years.8 In the University-based clinic at which I work, 51% of the vision rehabilitation clinic patients seen in the past year were younger than age 65.

In addition, connections the Vision Rehabilitation Service has made with local intermediate schools and teachers of the visually impaired have led to a growing patient base of children who have visual impairments. For instance, the fitting of bioptic telescopes, so teens who have visual impairments can gain or retain driving privileges, is becoming more common in the Eye Center.

So, if you think patient variety isn't possible with low vision rehabilitation, think again.

4 “Price is placed above functional improvement”

Although the examination and certain procedures can be coded medically, with rare exceptions, vision rehabilitation devices fall outside of both vision and medical insurance coverage.9,10 As a result, patients may opt out of purchasing a device that may benefit them. In my experience, however, I've found that the large majority of patients with vision impairment do purchase a recommended device regardless of whether their insurance covers it. The key to accomplishing this is to take the time to explain the specific benefit(s) of the device relative to the patient.

For instance, if a patient says she can no longer read to her children or grandchildren, she's likely to purchase a low vision device, such as a hand-held reader, if the low vision rehabilitation provider can show her how the device can enable her to revive this treasured pastime.

Something else to consider: For many, visual aids are a functional necessity, making a solution worth the price. For example, a patient who's unable to read his bills recognizes he'll lose his independence if he doesn't adhere to the recommendations of his practitioner.

Still not convinced? The Eye Center at which I work is located in a low socio-economic area. Yet, the average low vision rehabilitation patient spends approximately $260 per year on devices alone, and this doesn't include prescription spectacles, prisms or other dispensary-related items. For those patients who want to purchase a device, though can't afford it, we offer complimentary or low-cost used devices, payment plans, and we attempt to locate financial support from local or state organizations that serve the needs of patients who have visual impairments. It is our motto that no one goes without what they need, and yet our patient visits and device purchases have still produced strong financial dividends.

5 “It isn't profitable”

Low vision rehabilitation is feeling the same squeeze in medical reimbursements felt by other optometric areas. However, if billed correctly, this mode of practice remains profitable. Medical examinations can be billed multiple ways but are typically leveled based on the history components, such as the chief complaint and presence and extensiveness of the history of present illness, review of systems and past family and social history, the number of examination elements performed and medical decision-making.

The other option in medical billing is based on face-to-face time spent between the doctor and the patient. With regard to this, as long as at least half the face-to-face time is spent counseling the patient on such things as disease pathogenesis, progression, referrals to other professionals, orientation and mobility, safety, etc., you can bill based on time and obtain a nice reimbursement for the exam. To obtain reimbursement for low vision rehabilitation services, the 99000 or 92000 examination codes are typically used.

Keep in mind that examinations on patients who have visual impairments are commonly leveled higher than typical medical eye examinations for a number of reasons. These patients have complicated histories and disease. They very often need referrals to other healthcare providers, which you are coordinating. In addition, when billing is based on face-to-face time, the code level more accurately reflects the inordinate amount of patient counseling required to fully educate. So, even though a practitioner spends more time with each patient than in a typical examination, the higher coding levels reflect the time spent, resulting in higher compensation.

For instance, let's say you spend 60 minutes of face-to-face time with your new low vision rehabilitation patient, at least 31 minutes of which is counseling the patient. This examination would be correctly coded a 99205, reimbursing more than $200 in the metropolitan Detroit area.

Also, diagnostic tests, such as visual fields and ocular coherence tomography, are often necessary for management decisions. (Devices provide additional revenues, typically without the hassle or lag time involved in billing insurances.) And when performed, refractions and extended refractions are billed in addition to the comprehensive low vision rehabilitation examination. Something else to keep in mind: Utilizing a trained therapist may reduce doctor face-time and, depending on the credentials of the therapist or rehabilitation professional, be billable as device training or under the medical rehabilitation codes. More specific billing information, including required chart documentation, can be obtained through Medicare, other insurance carriers, college of optometry contacts or through other low vision rehabilitation providers.

In our clinic, the low vision rehabilitation clinic produces the highest per-patient revenue of any specialty area.

6 “Getting started is too expensive”

The need to purchase devices may at first appear overwhelming and costly. The reality is that with roughly $2,000, a practitioner can build an adequate device arsenal to get started. A supply of primarily low-powered illuminated and non-illuminated handheld and stand magnifiers, as well as low-powered telescopes is a great place to start. Assistance with the types of devices to purchase and their specifications can be obtained through device retailers or by contacting other low vision rehabilitation providers to get their input. Many state optometric associations have lists of these providers. I suggest membership in the American Optometric Association Vision Rehabilitation Section and the American Academy of Optometry Low Vision Section for direct connections with colleagues practicing in this area of optometry. (See “Resources for Developing a Low Vision Rehabilitation Practice,” below.) Many companies even offer pre-assembled starter kits, which may include an assortment of magnifiers, telescopes, microscopes or a combination. The manufacturers often loan the more expensive items, such as video magnifiers or portable electronic magnifiers, to optometry practices for a period of time at no cost or at reduced cost. This is because the companies appreciate practitioner growth in low vision rehabilitation and realize that doing this is mutually beneficial. Talking to a company salesperson or local sales representative is usually an effective way to inquire about loaner devices, as well as garner excellent practice management tips.

7 “It's not a core part of what we do”

Optometrists are rehabilitators. It is what we do. No other profession has the same understanding of functional vision. We are the primary eyecare profession that manages our patients from the cradle to the grave. Also, if it wasn't part of what we do, why would the curriculums in the colleges of optometry include course work and often labs on low vision rehabilitation? Further, why would optometric residencies and internships as well as conferences, online continuing education and workshops be available in this field?

Optometrists providing low vision rehabilitation services are typically part of an interdisciplinary team of professionals with unique skills and perspectives. The value of connectedness with other healthcare and rehabilitation professionals should not be underestimated.11 Optometrists could be viewed as the primary care physicians of the visual impairment world, coordinating and directing referrals to the appropriate sources. Serving as the kingpin in this type of healthcare network is a role optometry should embrace or risk losing.

Summing it up

The low vision provider connects patients who have visual impairments with the means to remain independent and the interventions that reactivate hope in the achievement of occupations, hobbies and activities of daily living. The aforementioned myths, viewed as fact by many in our profession, are preventing patients from improving their quality of life and optometrists from improving their bottom line. Hopefully, the busting of these myths will change this. OM

The Senior Stereotype
A very prevalent stereotype exists that seniors are difficult patients to please. My experiences and the experiences expressed by my low vision rehabilitation peers confirm that while challenging patients exist within any optometric specialty, our patients are overwhelmingly pleasant, loyal and appreciative. In fact, my geriatric patients tend to be the most grateful for the services I provide, as they confide that other doctors have treated them with a lack of dignity and respect.

Resources for Developing a Low Vision Rehabilitation Practice
American Optometric Association Vision Rehabilitation Section

American Academy of Optometry Low Vision Section

American Council of the Blind

American Foundation for the Blind

Council of Citizens with Low Vision International

Lighthouse International


National Association for Parents of Children with Visual Impairments

National Federation of the Blind

(1) Leonard, R. Statistics on Vision Impairment: A Resource Manual. Arlene R. Gordon Research Institute of Lighthouse International; 2002 April. 20 p.
(2) Lighthouse International. Prevalence of Visual Impairment. www.light house.org/research/statistics-on-visionimpairment/prevalence-of-vision-impairment. (Accessed Sept. 15, 2011)
(3) Michigan Optometric Association. Certification and Recertification. http://michigan.aoa.org/x10344.xml. (Accessed Sept. 19, 2011)
(4) LARA Michigan Board of Optometry. Department of Licensing and Regulatory Affairs. www.michigan.gov/mdch/0,1607,7-132-27417_27529_27546-59015--,00.html. (Accessed Sept. 20, 2011)
(5) Shoemaker, J. for Prevent Blindness America. Vision Problems in the U.S.: Prevalence of Adult Vision Impairment and Age-Related Eye Disease in America. 2008 www.preventblindness.org/sites/default/files/national/documents/vision-impairment-blindness.pdf. (Accessed Sept. 19, 2011)
(6) Brilliant, R. Essentials of Low Vision Practice. Boston: Butterworth-Heinemann; 1999. 7.
(7) Rosenberg, EA, Sperazza, LC. The Visually Impaired Patient. Am Fam Physician. 2008 May 15;77(10):1431-6.
(8) American Macular Degeneration Foundation. Stargardt Disease. www.macular.org/stargardts.html. (Accessed Sept. 20, 2011)
(9) Grover, LL. Strategy for developing an evidence-based transdisciplinary vision rehabilitation team approach to treating vision impairment. Optometry. 2008 April;79(4):178-88.
(10) Freeman, PB. Miles to go… Optometry. 2008 Nov;79(11):625-6.
(11) Stelmack, J. Emergence of a rehabilitation medicine model for low vision service delivery, policy, and funding. Optometry. 2005 May;76(5):318-26.

Dr. Hinkley is an assistant professor and chief of Vision Rehabilitation Services at Ferris State University's Michigan College of Optometry. E-mail her at SarahHinkley@ferris.edu, or send comments to optometricmanagement@gmail.com.

Optometric Management, Issue: October 2011