What is Instrument-Based Vision Screening?
Instrument-based vision screening refers to vision screening using an automated device
that can help identify vision conditions or risk factors that may cause decreased vision or
amblyopia.
1
An instrument-based vision screener takes an image of the eyes to measure
refractive error and ocular misalignments. It can be as quick and easy as taking a photo
with a digital camera.
1,2
Other names for instrument-based vision screening include
automated screening, autorefraction, objective screening and photoscreening.
3
Critical Impotance of Eye Health for Children
Vision problems are common among children, with 19 million worldwide living with a vision
disorder.
2
Oftentimes, vision disorders have no noticeable symptoms,
3
and as a result,
children may not realize they see the world differently than others.
4
Early detection and treatment of vision problems in childhood is critical, as 80% of vision
disorders can be prevented or cured.
2
Unfotunately, according to the Centers for Disease
Control and Prevention (CDC), only one in three children in the U.S. has received eye care
services before the age of six.
5
Uncorrected vision disorders can impact a child’s cognitive, emotional, neurological and
physical development, potentially resulting in behavior problems, interference with early
literacy and learning, and even permanent vision loss.
6
Among preschool children, less than 15% receive comprehensive
eye examinations and less than 22% undergo vision screening.
7
The evaluation of the visual system can help detect conditions like
strabismus and amblyopia that distot or suppress normal visual
images.
3
Without early detection and treatment, these vision
conditions may lead to permanent vision loss.
3
REIMBURSEMENT GUIDE
FOR INSTRUMENT-BASED
VISION SCREENING
What are the national guidelines related to vision screening?
The American Academy of Pediatrics (AAP) is the most influential specialty medical society in this space and
recommends that instrument-based screening may be used to assess risk at ages 12 months and 24 months, in
addition to the well visits at three through five years of age.
8
Bright Futures is an initiative led by the AAP and
aims to improve health outcomes for the nation’s infants, children and adolescents by increasing the quality of
primary and preventive care.
What are the appropriate CPT
®
codes to repot instrument-based ocular
screening?
There are two CPT codes available to repot instrument-based ocular screening:
• CPT code 99174 Instrument-based ocular screening (e.g., photoscreening, automated-refraction), bilateral;
with remote analysis and repot
• CPT code 99177 Instrument-based ocular screening (e.g., photoscreening, automated-refraction), bilateral;
with on-site analysis
What is the difference between CPT code 99174 and CPT code 99177?
Instrumentation and location of site are the elements that differentiate these two codes.
• CPT code 99174 describes the service where data is transmitted to a remote facility. The analysis and repot are also
compiled remotely.
• CPT code 99177 describes instrumentation that provides on-site, real-time analysis of the images. This does not
require electronic transfer of data for analysis. The physician is able to receive an on-site reading and repot.
Will insurance companies cover claims for CPT code 99177?
These are Category-1 codes, which are permanent codes for clinically recognized and accepted services that are assigned
values for payment.
The U.S. Preventive Services Task Force (USPSTF) recommends instrument-based vision screening with a “B” level evidence rating,
meaning there is high cetainty that the net benefit is moderate and that the practice should provide this paticular service.
2
The
Affordable Care Act requires health plans to cover preventative services that have an “A” or “B” level evidence rating.
2
What is the propotion of claims paid for CPT code 99177?
In 2018, 82% of claims submitted were covered services. The propotion of paid claims rose 6% between 2017-2018.
HILLROM REIMBURSEMENT GUIDE FOR INSTRUMENTBASED VISION SCREENING PAGE 2 OF 6
According to the AAP, children ages four and five should be presented
with visual acuity chats. Instruments can be used if the patient
is uncooperative or has a diagnosis of developmental delay.
12 months 24 months 3 years 4 years 5 years
What is the National Commercial Coverage Landscape for CPT code 99177?
HILLROM REIMBURSEMENT GUIDE FOR INSTRUMENTBASED VISION SCREENING PAGE 3 OF 6
STATE
AL AK AR AZ CA CO CT DC FL GA HI IA ID IL IN KS KY
COV. DENSITY 97% 60% 81% 78% 82% 77% 73% 96% 71% 84% 78% 87% 84% 63% 92% 81% 86%
LA MA ME MI MD MN MS MO MT NC ND NE NH NJ NM
NV
NY
91% 67% 81% 63% 89% 75% 91% 75%
60%
89% 79% 78% 92% 75% 68%
93%
89%
OH OK OR PA RI SC SD TN TX UT VA VT
WA
WI
WV
WY
76% 62%
93%
88% 89% 78% 62% 80%
70%
83% 83% 75% 77% 92% 86%
62%
Commercial Coverage Density By State
9
AIS Directory of Health Plans. 2017; National heatmap only considers sampled commercial payers in which covered ages are explicitly
stated or where an understanding of covered ages can be inferred (n=16). Results are weighted by plan size and regional presence.
Ages 1-5 are weighted evenly (e.g., 20% for each age covered).
WI
MO
AR
IA
KS
UT
ID
OR
CA
NV
OH
TN
SC
FL
MT
AZ
ND
WA
AK
HI
MN
WY
SD
NM
CO
NE
OK
TX
IL
MI
MI
MA
RI
CT
IN
LA
MS AL
NH
VT
NY
PA NJ
MD
WV
VA
NC
GA
KY
ME
DE
61 – 70%
71 – 80%
81 – 90%
91 – 100%
COVERAGE DENSITY
What is the National Commercial Payer Average for CPT code 99177?
HILLROM REIMBURSEMENT GUIDE FOR INSTRUMENTBASED VISION SCREENING PAGE 4 OF 6
2018 Commercial Payment Rate By State
*Average listed is based on fewer than 10 services.
10
Truven commercial claims data. Rates reflect payer payment for CPT code 99177 performed in the oce setting.
Unknown (<10 claims)
$7 – $12
$13 – $15
$16 – $19
$20 – $27
$28 – $82
PAYMENT RATE
WI
MO
AR
IA
KS
UT
ID
OR
CA
NV
OH
TN
SC
FL
MT
AZ
ND
WA
AK
HI
MN
WY
SD
NM
CO
NE
OK
TX
IL
MI
MI
MA
RI
CT
IN
LA
MS AL
NH
VT
NY
PA NJ
MD
WV
VA
NC
GA
KY
ME
DE
STATE
AL AK AR AZ CA CO CT DE FL GA HI IA ID IL IN KS KY
PAYMENT RATE $28 $33 $13 $13 $34 $12 $30 $24 $16 $37 $82 $14 $10 $12 $21 $10 $34
LA MA ME MI MD MN MS MO MT NC ND NE NH NJ NM
NV
NY
$16 $15 $13 $12 $27 $11 $25 $15
$11
$14 $21 $26 $35 $14 $22
$43
$25
OH OK OR PA RI SC SD TN TX UT VA VT
WA
WI
WV
WY
$17 $11
$20
$17 $16 $11 $11 $17
$12
$14 $15 $18 $16 $26 $29 $15
What age ranges are covered by CPT code 99177?
Covered ages vary by payer and individual plan. AAP is the most often cited specialty society in coverage policies. The 2016
AAP policy statement indicates instrument-based screening, if available, should be first attempted between 12 months and
three years of age and at annual well-child visits until acuity can be tested directly.
11
Some plans may cite USPSTF guidelines
as the basis for their coverage policy.
Children with a diagnosis of developmental delay (DDD) and who are unable to cooperate with standard visual acuity tests
may be covered for instrument-based vision screening by individual plans. Payers predominantly require DDD for children
ages four and five. Some commercial payers explicitly cover instrument-based vision screening for children with any
diagnosis.
Can I separately bill an evaluation and management (E&M) code and CPT 99177?
CMS’ National Correct Coding Initiative (NCCI) provides payers with guidance on proper claims adjudication, paticularly
when cetain codes are billed together. Per NCCI guidelines, CPT 99177 was separately payable with preventive E&M codes
until an October 2017 update. The AAP successfully lobbied for NCCI to remove the update effective July 2018. Healthcare
providers can appeal zero-dollar payment outcomes for claims on CPT code 99177.
What is the deductible and total cost burden for patients if the claim is denied?
The average patient deductible for unpaid claims was $2.87 in 2018. The reduced deductible amount ($6.80 in 2017)
suggests the average total patient cost share has decreased and will likely remain low.
For the same claims, deductible as a propotion of total patient cost share (inclusive of copay, coinsurance, etc.) decreased
from 80% in 2017 to 47% in 2018.
10
Can providers collect payment from patients for non-covered services?
Each provider will have their own policies on collection of non-covered services. Providers must inform the patient
that the services may not be covered. As pat of this process, the provider should have the patient sign a waiver
acknowledging the patient’s financial responsibility.
Is suppot available for payer advocacy?
The American Academy of Pediatrics (AAP) Payer Advocacy Advisory Committee (PAAC) has developed Issue Guidance
sheets on emerging payment issues. These can be used by AAP chapters and members to address specific payer issues.
Strategies and resources are provided on instrument-based vision screening and CPT 99177.
8
HILLROM REIMBURSEMENT GUIDE FOR INSTRUMENTBASED VISION SCREENING PAGE 5 OF 6
What is the average payback for instrument-based vision screeners?
Payback will vary based on patient volume, payer mix and local coverage policies. Many providers who invest in instrument-
based vision screening technology see positive returns in approximately one year if reimbursement is available
3
—the
national average for commercial coverage is $19.25.
10
In addition, the Americans with Disability Act offers federal tax advantages for the purchase of an instrument-based vision
screener.
3
Instrument-based vision screeners can be leased for as little as $149/month.
For more information on average coverage rates in your region, visit
hillrom.com/svsinvestment to request a Vision Screening Investment
Analysis from a Hillrom consultant that includes the following:
• Return on Investment (ROI) Analysis based on pediatric patient flow
• Customized repot of top-five payer payments by state
• Estimated pediatric vision screening exam coverage by age
hillrom.com
1
American Association for Pediatric Ophthalmology and Strabismus. Pediatric Vision Screening: Guidelines for Eective and Ecient Vision
Screening in Children.
2
Children’s Eye Foundation. https://www.childrenseyefoundation.org/see/. Accessed January 2, 2019.
3
Children’s Eye Foundation. A Practical Guide for Primary Care Physicians: Instrument-Based Vision Screening.
4
Prevent Blindness Wisconsin. Children’s Vision Screening. https://wisconsin.preventblindness.org/vision-services-and-programs-
childrenwisconsin. Accessed January 2, 2019.
5
Prevent Blindness Wisconsin. Our Vision for Children’s Vision: A National Call to Action for the Advancement of Children’s Vision and Eye Health.
https://wisconsin.preventblindness.org/sites/default/files/national/documents/OurVisionforChildren_2010_0.pdf. Accessed January 2, 2019.
6
National Association of School Nurses. Vision and Eye Health. https://www.nasn.org/nasn-resources/practice-topics/vision-health. Accessed
January 2, 2019.
7
Centers for Disease Control and Prevention. Keep an Eye on Your Vision Health. https://www.cdc.gov/features/healthyvision/index.html.
Accessed January 3, 2019.
8
https://www.aap.org/en-us/professional-resources/practice-transformation/getting-paid/Pages/Payer-Advocacy-Issue-Guidance.aspx
9
AIS Directory of Health Plans. 2017; National heatmap only considers sampled commercial payers in which covered ages are explicitly stated or
where an understanding of covered ages can be inferred (n=16). Results are weighted by plan size and regional presence. Ages 1-5 are weighted
evenly (e.g., 20% for each age covered).
10
Truven, Commercial Claims. 2016. Truven commercial claims data for services performed in the oce setting
11
Ocial Journal of the American Academy of Pediatrics. Eye Examination and Vision Screening in Infants, Children, and Young Adults.
http://pediatrics.aappublications.org/content/pediatrics/98/1/153.full.pdf. Accessed January 2, 2019.
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concerning coverage or levels of reimbursement. Payment will vary by geographic locality. It is always the provider’s responsibility to determine
accurate coding, coverage and claim information for the services that were provided.
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