According to the American Optometric Association, the definition of optometric vision therapy is: “Vision therapy is a sequence of neurosensory and neuromuscular activities individually prescribed and monitored by the doctor to develop, rehabilitate and enhance visual skills and processing.” * While the AOA and most optometrists understand “vision therapy” is a specialty discipline in optometry, insurance plans do not always adopt the same definition.
There are other terms that are often used, which can make things confusing, such as:
Orthoptics / Pleoptics: A medical procedure often used in vision therapy programs
Neuro-optometric Habilitation / Rehabilitation: A medically relevant therapeutic procedure similar to physical or occupational therapy but more visually based and performed by an optometrist.
Vision Training: A more educationally oriented program of visual skills and perceptual development.
Vision Enhancement: A more educational, or self-help approach to improvement of visual skills, processing, or visual clarity.
Sports Vision: A program of visual skills enhancement that is oriented towards bettering sports performance.
Notice that the first two terms are more medically oriented, whereas the last three are more educational or enhancement oriented.
Insurance plans want to make sure they are not paying for anything that is educational or enhancement in nature, therefore, they emphasize the importance of medical necessity, and provide very strict guidelines and allowances for coverage when orthoptics or neuro-optometric re/habilitation procedures are performed and billed. The patient must have very specific diagnosis, must have documented functional impairments, and there has to be a high level of research validity that the treatment procedures are effective. When all of these criteria are met, then the insurance may cover the vision therapy, but only when it is not specifically excluded in the plan. Many plans specifically exclude “vision therapy” and thus will not cover treatment even if a patient has a medically relevant diagnosis and functional impairment.
Furthermore, even when there is coverage for “vision therapy” in an insurance plan, the insurance will only cover the medical procedures and will not cover other procedures that they consider more educational or enhancement in nature. This means that to make a “vision therapy” session entirely medical requires the avoidance or elimination of many procedures that experience and research have shown to be highly effective and complementary to the medical procedures alone.
At Vision Clinics of Development & Learning, our experience with “watered down” programs that only include the medical insurance billable portions has led us to conclude that we are not serving the best interests / needs of our clients with such reduced programs. Therefore, we make a clear distinction between the medical portion of our programs and the educational/enhancement portions of our programs and communicate to you what portion of your program is medically billable, and what portion is not.
Vision Training refers to the portion of your program we recommend that is educational or enhancement in nature. Much like a private school we charge tuition for enrollment in our vision training programs. These programs are presented to you as an option for you to consider. It is your choice to enroll or not. Your enrollment contract will state that you understand that the Vision Training program you are purchasing is not medical and is therefore not medically necessary and will not be coded or billed to a medical insurance plan. The fees for such a program are collected separately from the fees for any medical procedures - they are never mixed together.
Orthoptics has a very specific medical procedure (CPT code 92065). Some insurance plans will cover orthoptics whereas others will not. Some have very strict guidelines and medical necessity review before considering coverage. The code is considered untimed, so it can be used by a clinic for any length of service provided in this category. It is a code that applies to very specific procedures usually using instruments and technology that address two eye coordination and eye focusing in particular, therefore it does not apply in all cases. The reimbursement levels for this code only allow for 15 to 30 minutes of provided service which may differ depending upon the insurance plan. Only when all the criteria are met can we bill out this code. If your insurance plan has coverage for this procedure, then we will provide orthoptics separately from any vision training we provide. For example, 15 minutes of orthoptics may be billed to your insurance, whereas the remaining 45 minutes is vision training and not billable to insurance. The two services are distinct.
This service involves two different CPT procedure codes 97530 and/or 97110. These are the same codes used by Occupational Therapists and Physical Therapists. When submitted by an optometrist, some insurance plans will cover these codes and others will not. The codes cannot be used for treatment that is better defined by orthoptics. The codes cannot be used for any of the educational/enhancement procedures that might be important in a comprehensive program. Also, insurance plans insist that the doctor him/herself provide the entire service and this makes the hour long session very expensive when the codes are not covered and passed onto the patient (such as deductibles and copays). Therefore, these codes can only be used when all criteria are met and only when scheduled directly with the doctor. In cases where these codes are necessary, it sometimes works better to collaborate with an occupational or physical therapist who can provide the therapy sessions with the doctor’s guidance.
Doctor’s visits are not technically therapy. Doctor’s visits are evaluation and management services. These services involve the doctor performing tests and measures, and then reporting progress, counseling on compliance, writing new prescriptions for procedures, coordination of care with parents or other professionals, and/or education of patients/parents on specific treatment procedures to follow. Most often, this kind of appointment is 15 minutes in length with the doctor. It may be longer, such as 30 minutes if there is more extensive tests or counsel that are needed. These kinds of charges are usually covered most easily by insurance plans. But there is also some reasonable limits to how often these services can be performed, so doctor’s visits do not substitute for therapy visits or vision training. Only the doctor can determine when and how often doctor’s visits should occur for various conditions.
Putting this all together, our clinic operates in the following manner:
We will propose the best practice approach to taking care of the condition we diagnose. And we will communicate clearly the non-medical optional visual training procedures we recommend as well as the medical and possibly insurance billable procedures we recommend to comprehensively address your situation.
The Vision Training Tuition and Materials fee will cover the non-medical, and non insurance billable procedures we recommend and if you chose these service you will sign an Advanced Beneficiary Notice that clearly states you have chosen to pay for these service privately without submission to an insurance plan. This is just like schools, tutoring, or other self-help services which are entirely private pay. These service are prepaid. They are not billed out for payment later.
For the medical and insurance billable services we will inform you of our network status regarding your insurance plan, and if necessary we will obtain the necessary prior authorizations before initiating treatment. These services will be processed just like appointments at any other doctors office and are subject to copays, deductibles, and coinsurance. Most often, these services are billed out to the insurance company first, and then when the clinic receives the explanation of payment we follow the copay, deductible, and coinsurance directives and send a monthly statement for any balance due from the parent/patient.