The New CPT Orthoptic Code #92066


The quite famous quote above is from “Through the Looking Glass” by Lewis Carroll, and comes to mind as the VT-OD List and VTODs on Facebook is abuzz about the new CPT Code 92066 for “Orthoptics”which went into effect this week. In a nutshell, 92065 which was formerly a technician code and reimbursed at a relatively low level (with an RVU or Relative Value Unit below 1.00) is now a code for when the doctor delivers the orthoptic care, reimbursed at a higher level (with an RVU above 1.00). 92066 is the new code for when technician delivers orthoptics, and will have a lower reimbursement rate than 92065. So for example, if 92065 was previously reimbursed at $30, its new level may be $45, whereas 92066 will be more like what 92065 had previously been, or possibly less.

All well and good, but this sidesteps the fundamental dialogue between Alice and Humpty. After all, what does the word “Orthoptics” mean, and what does its delivery as a therapeutic service encompass? Orthoptics means “straightening of the eyes” (from the Greek Ortho meaning straight and optikos for eyes) and, broadly speaking, the American Medical Association recognizes Orthoptics as a health care profession involved in the evaluation and treatment of disorders of vision, eye movements, and eye alignment in children and adults (source: The Boston Orthoptic Fellowship Program).

Let’s dig a bit deeper into Optometry’s usage of the term “orthoptics”. It was popularized in our profession by Dr. Louis Jaques, the father of binasal occlusion, who wrote a book in the 1930s titled Fundamental Refraction and Orthoptics. Dr. Jaques wrote on the topic for the OEP papers in the early 1930s, referring to orthoptics as “re-education” of the eyes and visual system. His terminology is going to seem strikingly prescient when we consider the potential applicability of the 97112 CPT code of “neuromuscular re-education” as it does or does not relate to orthoptics (we’ll discuss this later). Skeffington influenced Jaques to broaden and re-brand orthoptics as vision training, reflected in language used in subsequent OEP papers. Robert E. Bannon, the world’s leading expert in measurement and design of lenses for aniseikonia in the 1940s and ’50s (see Eikonometer target below) wrote a paper in the Australasian Journal of Optometry in 1947 titled Orthoptic and Visual Training. In it he struggled with the distinctions between orthoptics and visual training, citing issues that persist to this day.

bva_aniseikonia

In the 1960s through the 1970s, Dr. Bernard Vodnoy, who established Bernell Corporation to sell VT equipment, still conceptualized vision training or therapy as orthoptics. He published seven editions of a bound volume originally titled “The Practice of Vision Care, Orthoptics and Corneal Contact Lens Fitting”, the last edition in 1979 being titled “The Practice of Orthoptics and Related Topics”. It delved into the theory as well as practice of vision therapy, and it was clear from the contents of his catalog that Orthoptics was an umbrella term for the services offered through his materials.

As another illustration of how the term “Orthoptics” was being used, H.G. Parr of New South Wales, writing in the Australian Journal of Optometry in 1967, wrote about “Orthoptics and Visual Re-Education”, more in line with Jaques’ original terminology. Around this time, and during the 1970s, Optometry tried to develop its own set of codes (COPT – Current Optometric Procedural Terminology) to parallel what the AMA had done with CPT Codes, but that did not survive. ODs were left with the challenge of folding vision therapy into orthoptics (92065) if they wanted to obtain third party reimbursement for their patients.

In a paper that I wrote for the AOA Journal nearly 25 years ago, I pointed out why this was a shoe-horn effect that no longer made sense, because the field of vision therapy had moved well beyond orthoptics and was essentially a hybrid service. This meant that ODs had to be mindful of which services third party carriers considered to be medical versus educational (or at least non-medical) in nature. I referenced Dr. Mark Wright, who addressed this the year before in a chapter on third party rules and regulations in a monograph edited by Dr. Willard (Wid) Bleything.

Dr. Paul Freeman, editor of the now defunct AOA journal (Optometry) took a lot of heat for publishing my article on VT as a hybrid service. Particularly in institutional settings, there were certain individuals who were very vested in providing VT services based on third party reimbursement. But to his credit, Dr. Freeman stood by the merits of the article, and it helped catalyze the movement away from dependency on third party reimbursement. In a recent Town Hall meeting sponsored by the American Association of Certified Orthoptists, the reliance on third party reimbursement is still in evidence. They bemoan the fact that the certified orthoptist (C.O.) is not a state-licensed provider, and therefore presents challenges in terms of billing reimbursement profiles being downgraded to a technician rather than a professional code. This includes the challenges of dealing with insurance carriers who “bundle” two services into one. For example, if one bills 92065 along with a 92499 (unlisted ophthalmological procedure) or 92012 (intermediate exam) or 99211 (short e/m visit), will the carrier reimburse for only the service with the higher rate of the two?

While the trend toward independence from third party reimbursement tends to increase as one’s practice becomes more specialized, some practitioners (particularly those who are newer in VT practice or who are in institutional settings) still cling to third party reimbursement. In recognition of the need to advocate for proper reimbursement, the AOA has put out a manual that addresses these considerations which you can access here, and which includes commentary on use of the new 92066 code and re-wording of the former 92065 code. See in particular the discussions on pages 9 through 12.

As you will note, the use of the 97000 line rehab codes (such as 97110, 97112 and 97530) to substitute for 92065 or 92066 can be a gray area. The document emphasizes that you have to check with your state board in advance to know whether they will back you on these codes being within the scope of your licensure. Some states have issued in writing that they are; some indicate that they are not; and yet others take a neutral position stating that they are not affirming whether the 97000 codes either are, or are not within the scope of licensure.

A final observation about coding as far as time and complexity is concerned. The 97112 (neuromuscular re-education) code involves direct contact between the licensed provider (typically an OT or PT but not an assistant) and the patient. The code reflects a 15 minute time interval. Therefore, state-licensed therapists (or ODs in this case) who personally administer a VT session lasting 30 minutes of interaction time could bill for two units 97112, or one unit of 92065. This is because 92065 (or 92066 when the vision therapist is doing the therapy) is not a timed code. To reflect that the therapeutic interaction may involve a higher level of complexity, for example when working with a child who has severe developmental delays or a brain injury patient with severe cognitive compromises) some providers have used the two digit modifier code 22, billing 92065-22. The AOA document is silent on the issue of time or modifiers, but the advice would likely be to check with the carrier involved ahead of time to know what kind of documentation is required for the appropriate coding.

We can succinctly summarize by saying 92065 is now for docs, 92066 is now for therapists, and you’ll learn by trial and error what you can combine them with – pending what your state board allows and what individual plans will cover.

2 thoughts on “The New CPT Orthoptic Code #92066

  1. If a patient drops a prism into his shoe should we call it orthoptics or orthotics? Or would it depend on shoe size: 900 6 1/2 D? Perhaps Humpty knew best.

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