Ophthalmology and Optometry Coding Alert

Prepare to lose up to $73 on some surgeries - thanks to a 4.3 percent conversion factor reduction

For offices that perform vitrectomies with membrane peeling, the reimbursement outlook is bleak in 2006. Fees for this service take a dive from $1,429.87 in 2005 to $1,356.42 in 2006 - a loss of $73.45 per procedure when you report 67038 as the primary procedure.

Medicare has published its estimated relative value units and conversion factor for 2006, and the results aren't pretty. The proposed RVUs, published in the Aug. 8 Federal Register, indicate that the reimbursement for several common ophthalmic procedures may decrease next year.

Medicare carriers multiply a procedure's RVUs by a standard conversion factor, set every year by CMS, to determine the reimbursement for that procedure, says Stacy Tainsh, coder and billing manager for the American Eye Institute in New Albany, Ind. That conversion factor may drop 4.3 percent, from 37.8975 to 36.2679 in 2006, based on estimated figures published in a report, "Estimated Sustainable Growth Rate and Conversion Factor for Medicare Payments to Physicians in 2006."

The new conversion factor is only an estimate, the report stresses. "[T]he actual values for 2006 will be based on later data and will be published in the Federal Register by Nov. 1, 2005," the report says.

If this estimate proves accurate, however, here's how it will affect some common ophthalmic procedures, based on the proposed RVUs and unadjusted for geographical location: