Two reimbursement experts from the American Academy of Ophthalmology (AAO) provided a preview of the proposed Medicare payment changes for 2020, along with their analysis, during the AAO’s 2019 annual meeting in San Francisco.
“Overall, we expect ophthalmology payments to drop in 2020” from anywhere between 4% and 10%, explained David Glasser, MD, AAO Secretary, Medical Affairs. “Many of the [proposed] changes in valuation are due to ‘potentially mis-valued services.’” They have been proposed by the American Medical Association’s Relative Value Scale Update Committee (RUC). The Centers for Medicare and Medicaid Services (CMS) then decides whether to accept those recommendations.
The Category I code changes include revised codes for cataract, complex cataract, cyclophotocoagulation and corneal hysteresis; new codes for bundles of cataract and cyclophotocoagulation; and new and deleted codes for extended ophthalmoscopy (EO). Meanwhile, Category III code changes include a revised code for collagen cross-linking of the cornea and a new code for evacuation of meibomian glands.
Cataract-Related Code Changes
The cataract code changes were triggered primarily because cataract surgery and endoscopic cyclophotocoagulation (ECP) are commonly done together, explained Dr. Glasser. Thus, RUC recommended the establishment of two new codes:
The existing 66711 ECP code is being revised to specify that it be used when removal of crystalline lens is not performed. Providers are directed to use the new codes when the procedure is performed “at same encounter as extracapsular cataract removal with intraocular lens insertion.” Meanwhile, the existing code for extracapsular cataract extraction with IOL insertion (66984) will now specify that it be used when ECP is not performed. The same will hold true for complex extracapsular cataract extraction with IOL insertion (66982).
For the existing ECP code, said Dr. Glasser, “we recommended with RUC a decrease in work value by cross-walking the procedure to a similarly complex intraocular laser code, but CMS did not like that. They cut it further. We are not entirely pleased and are protesting that.” As for the two new codes when ECP is combined with regular or complex cataract surgery, CMS is suggesting carrier pricing, which gives Medicare contractors the authority to set the reimbursement level.
“There are problems with carrier pricing,” explained Dr. Glasser. Among them:
Most of all, “this disenfranchises two long-standing covered procedures,” he said. “RUC presented a rationale for the recommended price, supported by survey data.” However, “CMS did not present an alternative.”
CMS accepted the RUC recommendations for revised cataract and complex cataract procedures. This will mean an estimated 6% drop in reimbursement for cataract surgery (related to a 10% decrease in intraoperative time) and a 15% reduction for complex cataract surgery (reflecting the need for three vs four postoperative visits). The silver lining is that relative to some surgical procedures in other specialties—including cardiology and neurosurgery—the decreases for ophthalmology were smaller. “We were successful in defending the intensity and complexity of the procedure in the face of recommendations [for other specialties] that were in the 20% to 40% range,” said Dr Glasser. In that light, a 15% reduction is a minor victory.
Ophthalmoscopy Volume Introduces Scrutiny
According to Michael Repka, MD, AAO Medical Director, Government Affairs, “extended ophthalmoscopy has come into review because the volume was going up at a faster rate that exceeded some detection screens,” leading RUC and CMS to conclude that “the procedure is overvalued and it is being overused.” The recommended changes are to eliminate initial and subsequent EO with retinal drawing (92225 and 92226, respectively), and replace them with:
“So, you are going to be paid for these procedures at around $10 to $12,” plus practice expenses, said Dr. Repka.
Corneal Hysteresis: Getting Used to New Technology
Corneal hysteresis (92145) is being recommended for a cut because clinicians are getting acclimated to this new technology and, thus, it presumably costs less to do, explained Dr. Repka. The current RVU is 0.17. RUC recommended a 0.10 RVU, which CMS accepted.
Finally, there are two Category III code changes:
Glasser D, Repka M. Medicare update forum. Presented at: AAO 2019 annual meeting; October 12-15, 2019; San Francisco.