Ophthalmology and Optometry Coding Alert

Blame ophthalmology and optometry payment cuts on budget neutrality.

Expect some give and take in the calendar year (CY) 2024 Medicare Physician Fee Schedule (MPFS) proposed rule. Actions everyone can get behind include the feds further advancing value-based care and expanding access to critical medical services. But on the flip side — eye care providers may be facing more payment cuts in the coming year.

Context: On July 13, the Centers for Medicare & Medicaid Services (CMS) issued its CY 2024 MPFS proposed rule. The 2,033-page fee schedule is chock full of proposed billing revisions and payment provisions, which include updates surrounding key issues like evaluation and management (E/M) services and telehealth.

Here’s a glimpse at four proposals you should keep an eye on.

1. Pay Rate, Conversion Factor Reduction Looming

The rule proposes cutting the 2024 MPFS conversion factor (CF) to $32.75, which represents a decrease of $1.14 (or 3.34 percent) from the 2023 CF of $33.89, reducing Medicare payment rates by 1.25 percent. This reflects the expiration of the 2.5 percent statutory payment increase for CY 2023, a 1.25 percent statutory payment increase for 2024, a 0.00 percent conversion factor update under the Medicare Access and CHIP Reauthorization Act, and a -2.17 percent budget-neutrality adjustment.

CMS has said that proposed payment increases for primary care and other direct patient care providers meant that payment cuts must occur in other specialties to achieve budget neutrality. While specialties like internal medicine and family practice would see reimbursement increases, 1 and 3 percent respectively, others are facing cuts, including ophthalmology (-1 percent) and optometry (-2 percent).

2. Controversy Surrounds Add-On Code for Complex E/M

CMS has finally decided to make add-on code G2211 (Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient’s single, serious condition or a complex condition) effective in 2024. The code is intended to account for visit complexity associated with certain office/outpatient (O/O) evaluation and management (E/M) services. The additional payment for G2211 aims to better recognize and account for the inherent costs clinicians may incur when longitudinally treating a patient’s single, serious, or complex chronic condition.

History: HCPCS Level II code G2211 was originally proposed three years ago, but due to pushback from the American College of Surgeons and other surgical specialties, Congress delayed the implementation of the code. The same coalition will once again be urging Congress to stop or delay the G2211 code from being implemented, which would eliminate the majority of the anticipated 2024 cut.

Refinements to the G2211 policy include:

1) A proposal not to pay for G2211 when simultaneously billed with an O/O E/M visit that has payment modifier 25 (Significant, separately identifiable evaluation and management service by the same physician … on the same day of the procedure or other service) appended, as that denotes the O/O E/M visit is itself unbundled from another service.

2) An adjustment of the utilization estimate for G2211 from 90 percent of O/O E/M visits billed by certain physician specialties (roughly 58 percent of all office visits) to instead being billed with 38 percent of all O/O E/M visit claims initially, But in several years, when G2211 is fully adopted, CMS predicts the HCPCS Level II code will be billed with 54 percent of all O/O E/M visits.

Despite these revised utilization assumptions CMS is proposing, G2211 continues to drive a significant payment reduction to the PFS overall for CY 2024. Specifically, the agency notes that approximately 90 percent of the -2.17 percent budget neutrality adjustment to the CF for CY 2024 is attributable to G2211, with all other proposed valuation changes making up the other 10 percent.

3. Telehealth Flexibilities Can Continue

The rule, if enacted as proposed, will make healthcare more accessible to all populations. For example, CMS is proposing to:

• Add health and well-being coaching services CPT® codes 0519T-0593T to the Medicare Telehealth Services List on a temporary basis for 2024.
• Permanently add the proposed new HCPCS Level II code for SDoH risk assessment to the Telehealth Services List.
• Temporarily expand the scope of telehealth originating sites to include any site in the United States where the patient is located at the time of service.
• Continue the expanded scope of telehealth practitioners to include qualified occupational therapists, physical therapists, speech-language pathologists, and audiologists.
• Pay for telehealth services furnished in a patient’s home — POS 10 (Telehealth provided in patient’s home) — at the higher, non-facility PFS rate. POS 2 (Telehealth provided other than in patient’s home) will remain as-is, paid at the facility rate.

The proposed rule would also serve to officially extend many of the flexibilities to coverage allowed during the public health emergency (PHE) for COVID-19 through 2024, including direct supervision via telehealth through real-time audio and video and periodic assessments furnished via audio-only telecommunication.

CMS is also proposing a new process for adding, removing, or otherwise changing codes on the Medicare Telehealth Service list.

Jerry Penso, MD, MBA, president and CEO of the American Medical Group Association (AMGA) commended CMS for “proposing reimbursement policies that treat telehealth care as equivalent to in-office care. It has become evident that the cost of treating patients through telehealth does not differ from an in-person visit, and AMGA is pleased that CMS’ proposal for Medicare reimbursement policy reflects this fact.”

4. Policy To Redefine ‘Substantive Portion’ on Hold

In addition, CMS intends to keep the current split/shared rules for a little bit longer, opting for another delay, with a start date now slated for Jan. 1, 2025. CMS finalized implementing its split/ shared policy that the provider who administers the substantive portion of the visit bills for the E/M services — whether it’s the physician or the nonphysician practitioner (NPP) — in the CY 2022 MPFS final rule and then delayed the implementation once already in the CY 2023 MPFS final rule.

Heads up: Under this policy, if a NPP performs at least half of an E/M visit and bills for it, Medicare would only pay 85 percent of the MPFS rate, compared to a physician’s 100 percent.

Hear What Industry Leaders Are Saying

Provider organizations have decried the proposed payment cuts.

“Medicare already largely fails to cover the cost of furnishing care to beneficiaries, and the proposed cut to the 2024 conversion factor compounds the problem,” said Anders Gilberg, MGA, senior vice president for government affairs at the Medical Group Management Association. “Congress must reexamine existing law to provide an annual physician payment update commensurate with inflation and do away with Medicare’s ‘robbing Peter to pay Paul’ budget neutrality requirements to provide much-needed financial stability for medical practices.”

The AMA also panned the cut and heightened calls for Congressional reform to the Medicare physician payment system. “When adjusted for inflation, Medicare physician payment already has effectively declined 26% from 2001 to 2023 before additional inflation and these cuts are factored in … This is almost biblical in its impact. Seven lean years that include a pandemic and rampaging inflation. Physicians need relief from this unsustainable journey.” AMA President Jesse Ehrenfeld, MD, MPH, said in a statement.

Comments: If you want to offer your two cents on these or other policies, you have until Sept. 11 to weigh in.

Resource: Check out the MPFS proposals, which include instructions on commenting, at https://public-inspection. federalregister.gov/2023-14624.pdf.