Ophthalmology and Optometry Coding Alert

You'll earn 32 percent more for B-scans, and lose over 40 percent for some conjunctival surgeries There's good news and bad news for ophthalmology coders in the recently released 2005 Medicare fee schedule, and depending on your most commonly performed procedures, you may come out ahead of - or behind - the game.

CMS has increased the conversion factor from 37.3374 to 37.8975, which translates to a 1.5 percent increase in payments across the board for physician services next year. In general, Medicare multiplies the RVUs for a procedure by the conversion factor to arrive at the allowable reimbursement for a given procedure. The fee schedule appeared in the Nov. 15 Federal Register and goes into effect Jan. 1, 2005. Welcome a Big Boost to Diagnostic Ultrasound Codes Ophthalmology practices will see big increases in the reimbursement for 76511 (Ophthalmic ultrasound, diagnostic; quantitative A-scan only) and 76512 (... B-scan [with or without superimposed non-quantitative A-scan]). RVUs for A-scans are going up from 2.86 to 3.47 (a 23 percent increase) and B-scans are going from 2.52 to 3.29 (a 32 percent increase). After you multiply the new RVUs by the new conversion factor, both procedures should bring in over $120 apiece per visit.

Thank the AAO: "We were able to argue for these increases based on members' responses to our surveys on practice expenses and work values," says Denna Bruce, head of OPHTHPAC, the America Academy of Ophthalmology's political action committee.

You will also see a net increase in the RVUs for many commonly reported evaluation and management codes. In some cases, the RVUs will decrease, but overall reimbursement will be offset by the increase in the conversion factor. Say Goodbye to Office Surgery RVUs The news is not so good, however, for ophthalmologists who perform certain surgical procedures outside a facility setting. CMS is slashing the nonfacility RVUs for several eye surgery codes by over 50 percent. The new RVUs are based on CMS surveys of practice expenses.

Example: In 2004, CPT code 68040 (Expression of conjunctival follicles [e.g., for trachoma]) had 5.71 non-facility RVUs, yielding $213.20 in reimbursement when multiplied by the conversion factor. In 2005, the RVUs will shrink to 1.60, reimbursing $60.64 - a 71 percent difference. The nonfacility RVUs will then be closer to the facility RVUs (1.26 in 2004, 1.32 in 2005).

Other big RVU losers in 2005 are:
   65430 (Scraping of cornea, diagnostic, for smear and/or culture): 6.49 nonfacility RVUs in 2004, 2.83 RVUs in 2005, $135.07 loss
   68020 (Incision of conjunctiva, drainage of cyst): 7.13 nonfacility RVUs in 2004, 2.85 RVUs in 2005,      $158.21 loss
   68135 (Destruction of lesion, conjunctiva): 7.24 nonfacility RVUs in 2004, 3.74 RVUs in 2005, $128.59 loss
   68770 (Closure of lacrimal fistula [separate procedure]): 20.10 nonfacility RVUs in 2004, [...]