Article

Incorporating a Low Vision Rehabilitation Service into a Retinal Practice

AMD still often requires low vision referrals. Does it make sense to incorporate such a service into your practice?

Willie Sutton, the infamous American bank robber was once asked by a reporter why he robbed banks. His now well-known answer was reported, “I rob banks because that’s where the money is.” Applying this line of reasoning to providing low vision rehabilitation (LVR) care, these services should be offered in retinal practices, ie, the “low vision bank,” where the greatest concentration of low vision patients can be found anywhere on the planet.

A chart review in our office found that 18% of our patients had binocular acuity worse than 20/60. Of these low vision candidates, most had AMD: 51%, with exudative AMD; and 16%, atrophic. Retinal conditions caused the primary impairments of 90% of our patients referred to LVR programs over the last 25 years.

Roughly 25 years ago, Retina Consultants of Southwest Florida started an in-house LVR service that has functioned nonstop to the present day. While many different locations can work effectively in providing LVR care, there are some unique advantages to providing care within a retinal practice that may be worthy of emulation.

WHY DO LOW VISION REHABILITATION?

Many pathologies commonly seen in retinal practice result in patients being left with permanent vision loss — such as macular degeneration, diabetic retinopathy, retinal vascular occlusions, retinal detachments, hereditary retinopathies.

If we reflect about why we are in retinal practice, it should be obvious that we want to ensure optimal care for these patients. However, in caring for these patients, is it sufficient to flatten the retina, or should we also be concerned with whether the person with the flattened retina can use it to read the newspaper?

Treatment of these retinal pathologies is not complete if the patient is not restored to functional capacity. Is it not preposterous to think of an orthopedic surgeon amputating a limb and sending the patient on his or her way with nothing more than a cheery “good luck and hop along happily”? No, the physical therapist is often onsite, and a prosthetics fitting is part of the care plan. Does this standard not seem reasonable to expect in ophthalmology as well?

LVR is well documented as being effective for these patients. Below are the outcomes of one of our low vision services that provided a high level of rehabilitation care to 220 patients. The patients received, on average, five hours of care from an MD and an occupation therapist. Overall, 80% of goals were accomplished, and quality of life and independence were dramatically improved.

Another somewhat self-serving reason for providing LVR care is that it is good for practice referrals. A quality LVR service often attracts the attention of referring optometrists and ophthalmologists. Patients who do not require surgical or medical intervention also end up being referred.

Even referrals from direct competitors will find their way to the practice when those competitors are honest about the needs of their patients. There are only very few ODs or MDs who want to do offer their own LVR, and the retinal practice will have to be conscious of those caregivers working among them who would like their patients referred back for care.

BENEFITS OF IN-HOUSE LVR

The first and obvious benefit to providing in-house LVR is that patients receive the care that they need to improve their quality of life. However, one of the significant obstacles to the process is patient resistance. Whenever a patient is referred to another treatment facility, there is always a concern with whether he or she will follow through and attend the visit. Compliance is certainly an issue when a referral to LVR is made.

For example, many good LVR programs are housed in excellent facilities that have names including the phrase “Institute for the Blind.” To make the visit, patients must assume a new and very difficult label — that they are “blind.”

There are many negative stereotypes associated with blindness that are difficult to internalize before that trip can be made. A 20/70 patient with some difficulty in reading has not internalized a stereotypical “blind image” of him-/herself selling pencils on the street corner with a tin cup and white cane in hand.

Rehab Model Outcomes
Warren, Fletcher et al
(average 5 hours of training, N=220)
GOAL ACHIEVED PARTIAL UNSUCCESSFUL
Effective Use of Device 75% 22% 3%
Meal Preparation 84% 8% 8%
Self Care 82% 8% 10%
Handwriting 82% 13% 5%
Shopping 83% 0% 17%
Sewing 62% 15% 23%
Overall 80% 15% 5%

When an LVR service is present in the retinal practice, the patient is simply told, “We would like you to make your visit next week to see Dr. Fletcher. He is one of our doctors who specializes in helping patients to read and use their vision effectively.”

A much higher percentage of patients will come to their familiar practice setting to undergo LVR than will go to an unfamiliar setting with a threatening sounding name, which may include the scary “B” word.

When patients are referred within the practice, they correctly identify their rehabilitation treatment as part of the continuum of care that they are receiving for their retina. It is comfortable and natural to just see another member of the practice. It is a seamless transition to participate in LVR care.

SCREENING CRITERIA FOR LVR

There are some easily administered screening techniques that help a practice to identify who might benefit from LVR services. Across all diagnoses, any individual whose best-corrected visual acuity is worse than 20/60 is going to have reading difficulty and will likely benefit from LVR.

In addition, there are contrast sensitivity and central visual field disruptions that may cause significant functional difficulties, while relatively good acuity is maintained. For example, it is common for patients with geographic atrophy to have large ring scotomas surrounding foveal fixation, where good acuity is maintained. These patients have great need for LVR with acuity that may be as good as 20/30.

An easily administered screening technique is to have the technician who is taking the patient history ask a routine question, such as “Do you have trouble reading the newspaper, even with your best glasses?” A positive response would indicate that it may be appropriate for the patient to be referred for LVR. A check box on the EHR can then trigger a referral to the in-house LVR service.

EQUIPMENT

Compared with a new OCT, outfitting an LVR clinic is relatively inexpensive. With an expenditure of approximately $5,000, a good service can be offered. Basic LED-illuminated magnifiers provide great value at roughly $25. Close focus prismatic half-eye spectacles are a mainstay of vision rehab and run about $50. Portable video magnifiers can give print access to even profoundly impaired patients with a cost of less than $500.

There is a growing array of off-the-shelf electronic products that provide tremendous assistance. For example, using an HDMI cable and a 32-inch TV as a computer monitor will cost less than $200. Using a Kindle app (Amazon.com, Seattle) on an 18.5-inch tablet is possible for about $500. It might be wise to ask vendors of higher priced devices if you can have one unit as a demo.

PERSONNEL

Utilizing the right personnel is a key to success in this discipline. Low vision is not cured with optics — training is the secret to success. Rehabilitation requires adaptive skills that take time and practice to develop. For example, eccentric fixation with a macular scar is necessary in many patients, but only with considerable practice does it become effective.

An optometrist or ophthalmologist with a special interest in LVR is the first professional that low vision patients will see for an evaluation. It is also essential that specially trained occupational therapists (OTs) be part of the program. These OTs can work in the office or for a home health agency; the latter will let them visit patients in their home environments.

BILLING AND FINANCIAL CONSIDERATIONS

Medicare reimbursement is available for LVR services, so while CMS is not a huge source of revenue, LVR can be self-supporting. Since 2004, CMS has had a national policy in place that allows CPT rehabilitation codes to be used for the ICD diagnoses of visual impairment. Most low vision doctors use an E&M office visit code, a visual field test code, and perhaps a prolonged service code for the initial evaluation.

The OT working in the retinal practice can bill under Part B of Medicare in the retinal office or can use appropriate Part A charges if they work in other types of settings. Part B reimbursement for OTs pays more than $100 per hour for face-to-face treatment (eg, 97534 in 15-minute increments).

Payer coverage and documentation guidelines for low vision services should be researched thoroughly. Review of CMS Online Coverage Manuals, NCD, and your local MAC LCD guidelines for Therapy Services should be completed before any decision is made.

While traditional Medicare will allow coverage for LVR, and Medicare Advantage plans should follow Medicare guidelines, confirming benefits is strongly recommended. Commercial plans may or may not have policies in place for LVR. Benefit calls should include CPT and ICD-10 code specific questions to ensure proper coverage data is obtained.

Compensation for the professionals providing the LVR service is an important consideration. We have found that a productivity-based model of compensation has great merit. Everyone involved should have some “skin in the game” to achieve a financially successful LVR practice. A fair percentage of collections can be ascertained, taking into consideration the projected revenue and direct costs.

A percentage of practice overhead should be assigned based on the services to be utilized, such as front office (scheduling and check-in/out) and billing. Don’t forget to include the sale of LVR devices in the compensation model. This is an area where you have more flexibility to determine the percentage of the profits that should be allocated to the physician.

A CASE IN POINT

We recently had a delightful woman referred by one of our retinal physicians to the low vision rehab service. She was in her late 90s and had been receiving anti-VEGF injections for more than a year. The first words out of her mouth were delightfully disarming: “You know, sonny, when you are nearly 100, you slow down a little bit. I am not running races any longer, and that gives me more time for reading now. But darn it, I don’t see well enough to read any longer. You’ve got to do something about that!”

Like many posttreatment exudative maculopathy patients, she had a moderate reduction in VA (20/80) with a relative scotoma present centrally. With 4X magnification, optimal illumination, and some simple OT instruction, she was back to reading in no time and happy about it!

She was a political junkie and wanted to keep up on the mudslinging taking place in the primaries. When I asked her how long she planned to live, she replied, “At least until November. I want to see who wins the election. After that though, I may want to die!”

LVR is really the bottom line in what we do as retinal doctors. It is where the retinal rubber meets the road. Ignore it, and you won’t be truly getting full traction in helping your patients. RP