Ophthalmology and Optometry Coding Alert

Plus:  See how cataract removal fares against Medicare's 4.4 percent conversion factor cut

Although the RVUs for many of the most commonly reported ophthalmic codes have stayed the same--or even gone up slightly--a 4.4 percent drop in Medicare's conversion factor means that your practice will be earning less for most procedures in 2006.

In its final rule, "Revisions to Payment Policies Under the Physician Fee Schedule for Calendar Year 2006," published Nov. 2 in the Federal Register, Medicare announced a 36.1770 conversion factor for next year. Medicare carriers multiply a procedure's RVUs by the conversion factor to determine the reimbursement for that procedure, says Karen Rousseau, insurance coordinator for Eye Vision Associates in Lake Ronkonkoma, N.Y.
 
Worse than expected: This new figure is a drop of 4.4 percent from the 2005 CF of 37.8975, but the final conversion factor is even lower than Medicare predicted it would be earlier this year. CMS had estimated a 36.2679 CF, based on estimated figures published in a report, "Estimated Sustainable Growth Rate and Conversion Factor for Medicare Payments to Physicians in 2006." (See "Brace Yourself: Proposed Schedule Slashes Fees for Most Eye Procedures" in the September 2005 Ophthalmology Coding Alert.)

Higher-valued procedures will see the biggest reductions, although the RVUs assigned to them may increase. For example, the nonfacility RVUs for pan-retinal photocoagulation, CPT code 67228 (Destruction of extensive or progressive retinopathy [e.g., diabetic retinopathy], one or more sessions; photocoagulation [laser or xenon arc]), will increase in 2006--from 24.82 to 24.86. But the lower conversion factor more than offsets the difference:

2005 payment: 24.82 x 37.8975 = $940.62
2006 payment: 24.86 x 36.1770 = $899.36
Difference: -$41.26 in 2006

Other casualties: Expect to see $31 less for 66984 (Extracapsular cataract removal with insertion of intraocular lens prosthesis [one stage procedure], manual or mechanical technique) and $63.11 less for 67038 (Vitrectomy, mechanical, pars plana approach; with epiretinal membrane stripping), even though the RVUs for those procedures are not decreasing.

The final rule, which is awaiting Congressional approval, takes effect Jan. 1, 2006. To see the complete ruling (CMS-1502-FC), visit the CMS Web site www.cms.hhs.gov/physicians/pfs/.