Therapists to Assist the
A viable option in assisting low-vision patients.
BY MARY WARREN, MS, OTR/L
It is estimated that approximately 1 in 28 adults over the age of 40 in the United States have low vision, a number that is expected to increase significantly over the next 20 years due to an aging population.1 Although, by definition, people with low vision have some usable vision, they often have difficulty using their remaining vision to complete necessary tasks, particularly those with small or low contrast visual details. Reading and writing legibility are almost always significantly compromised. Difficulty performing these 2 tasks creates limitations in many other daily activities such as grooming, meal preparation, medication management, financial management and shopping.
Persons with visual impairment are 3 times more likely to report difficulty preparing meals, 4 times more likely to experience difficulty shopping for groceries and almost 5 times more likely to report difficulty managing medications.2 Their visual limitations also increase the risk of other injuries. For example, those with low vision report difficulty in many potentially dangerous activities such as using knives to prepare food, judging depth on stairs and curbs, identifying medications, accurately dialing telephone numbers such as 9-1-1, and identifying spoiled foods and water spilled on floors.
EMPLOYING OCCUPATIONAL THERAPISTS
For years, retinal specialists have been aware that their patients are struggling and have sought out low-vision rehabilitation services through the traditional network of state, federal, and charitable agencies. Although the services provided are excellent, chronic underfunding and manpower shortages create long waiting lists and limited services, especially for older adults. In the early 1990s, Donald Fletcher, MD, took a different approach and began using occupational therapists (OT) to provide rehabilitation services through the healthcare system. Through the diligent efforts of Dr. Fletcher and other ophthalmologists, Medicare formalized coverage of OT services for its recipients with low vision in a 2002 program memorandum that outlined the conditions for reimbursement including accepted IDC-9 and CPT codes.3 A year later, Medicare reduced its restrictions and began permitting physicians to hire OTs into their practices to provide rehabilitation services.
Occupational therapy is a rehabilitation discipline that assists individuals with disabilities to achieve independence in all areas of their daily life according to the American Occupational Therapy Association at aota.org. Occupational therapy practitioners enter practice with either a bachelor's, master's or doctorate and work with persons in a wide variety of settings. Most OTs do not graduate with specific expertise in low-vision rehab but acquire this expertise through postgraduate education. There are a number of ways this education is obtained. The focus of OT intervention in low vision is to enable the person to safely and independently complete the daily occupations compromised by visual impairment.4 This is accomplished by teaching a low-vision individual to use remaining vision as efficiently as possible while simultaneously modifying activities so they can be completed with less vision or without vision. Training the low-vision person to use adaptive devices such as magnifiers to complete daily activities is a key component of the rehab process along with the use of the home visit. Home visits are necessary because visual environment is critical to the ability to use remaining visual function and this environment cannot be accurately replicated in the clinic.
Occupational therapists evaluate the patient's performance of daily activities within the home and recommend and implement home modifications to ensure the safety and independence of the person. The length of the occupational therapy intervention depends on the severity of the person's vision loss and limitations, but in most cases, is completed within 4 to 6 treatment sessions. Therapy can always be reinitiated at a later date if a follow-up visit with the physician shows that the patient has lost more vision and is experiencing additional limitations in daily living activities. Because two thirds of persons with low vision are over the age of 65, Medicare part B is the primary reimbursement source for therapy services. To bill Medicare, OT services must be provided in compliance with federal, state, and local regulations. This includes the requirement that services are provided under the direction of a physician who orders the therapy services and is responsible for the medical direction of the therapy program. Occupational therapists are well versed in the documentation requirements of Medicare and other third-party payers needed to obtain reimbursement.
POSSIBLE BILLING MODELS
One of 2 billing models is generally adopted when an OT joins an ophthalmology practice: The OT provides rehabilitation services under the physician's Medicare provider number, or the OT obtains a personal Medicare provider number and assigns over reimbursement to the practice. In both cases, the OT usually works as an employee of the practice. In the first model, Medicare views the services provided by the OT to be a direct extension of the physician. Therefore, the physician must be present on the premises whenever the OT is working with patients and the OT cannot bill for services if the physician is out of the office. The OT is also unable to conduct a home visit unless the physician comes along. These restrictions can cause down time and under-utilization of the OT, and because of this, most practices adopt the second model. With independent provider status, the OT is able to conduct home visits and work with the patient in the community and also work with patients when the physician is on vacation.
The best practice model is one that incorporates not just the OT, but also a low-vision optometrist into the practice. Occupational therapists trained in low-vision rehab are well versed in the practical application of using optical devices to complete daily activities and methods to train the patient in using such devices. However, they do not have the knowledge of physiological optics possessed by low-vision optometrists to ensure that the patient's magnifier provides the very best optical enhancement. The best version of this practice model is one where the patient is referred to a low-vision optometrist for prescription of the optical devices and the OT then trains the patient in the application of the device to complete daily activities. The services of the low-vision optometrist can be obtained in at least 2 ways. The optometrist may be a member of the retinal practice or receive referrals from the practice to prescribe the optical device and then send the patient back to the practice and the OT for therapy services. The OT is responsible for working with both the optometrist and retinal specialist to ensure that the patient achieves the best rehab outcome.
ADDING AN OT TO A PRACTICE
There are several advantages to adding an OT to a practice. First and foremost it provides an important alternative to the often delivered line "there is nothing more I can do for you" when confronted by the patient with irreversible and progressive vision loss. Low-vision rehabilitation services delivered by a resourceful and caring OT will improve the quality of life and independence of a person who otherwise will face a continued downward spiral. In addition, by adding low-vision rehabilitation services in-house, the referral process is streamlined; the patient can merely set an appointment to return to the familiar setting of the physician's office. This reduces the patient's stress level and increases the likelihood that the patient will follow through and receive this much needed intervention. Collaboration with the OT also allows the retinal specialist to interact with the patient over a longer period of time.
The OT typically works with the patient over a 6 to 8 week period, usually seeing the patient once a week. While therapy is in progress, the OT will regularly communicate with the physician about the patient's improvement. The education that the OT provides during treatment encourages patients to be more proactive regarding management of their eye disease and to return to the physician for additional treatment if changes in vision are detected. The OT can also reinforce the physician's recommendations during treatment and increase patient compliance. The final reason for adding low-vision rehabilitation services is that it creates good will for the practice within the community by demonstrating that the physicians care about the well-being of their patients. RP
1. The Eye Diseases Prevalence Research Group. Causes and prevalence of visual impairment among adults in the United States. Arch Ophth. 2004;122: 564-572.
2. Crews, JE. Patterns of activity limitation among older people who experience vision impairment. In Stuen C, Arditi A, Horowitz A, Lang MA, Rosenthal B, Seidman KR, (eds.). Vision Rehabilitation: Assessment, Intervention and Outcomes. 2000; 754-757. Exton PA: Swets & Zeitinger.
3. Mogk L, Goodrich G. The history and future of low vision services in the United States. Journal Visual Impairment and Blindness. 2004;98: 585-600.
4. Warren M. Providing low-vision rehabilitation services with occupational therapy and ophthalmology: a program description, Amer J Occupat Ther. 1995;49: 877-884.
Mary Warren MS, OTR/L is an assistant professor of occupational therapy and director of graduate certification in low vision rehabilitation at the University of Alabama at Birmingham.