Ophthalmology and Optometry Coding Alert

Heavy pay cuts for your ophthalmologist's services could be on the horizon, according to the proposed Medicare Physician Fee Schedule, printed in the July 13 Federal Register.

CMS is projecting a record 21.5 percent rate cut, and proposes halting payment for consult codes in 2010. Instead of reporting consult codes (for example, for hospital patients who develop ocular complications such as blurring or eye pain), you'd report new or established patient office visit or hospital care (E/M) codes for these services, and CMS would increase payments for the existing E/M codes.

To determine the impact of this change, you'd have to compare the reimbursement from the new fee schedule office visit fees vs. the current office consult fees, as well as the new hospital visit E/M charges vs. the current hospital consult fees, says Quinten A. Buechner, MS, MDiv, CPC, ACS-FP/GI/PEDS, PCS, CCP, CMSCS, president of ProActive Consultants in Cumberland, Wis. Using this year's figures, you'd lose between $16 to $45 for office consults that would now be coded as new patient visits, and you'd lose $30 to $100 for established office consults coded as established patient follow-up visits, Buechner says. A rough calculation shows that the additional E/M payments (proposed at 6 to 8 percent) may not cover the loss of consult money. This could cause pay cuts for specialists in particular, who bill consults more often than primary care physicians.

The industry reacts: "There can be no meaningful health care reform without long-term reforms to the Medicare physician payment system," says a statement from the American Society of Cataract and Refractive Surgeons (ASCRS). "The physician community does not support another short-term 'fix' that only temporarily prevents Medicare payment cuts."

Bright side: CMS is proposing that it will use data taken from the AMA's Physician Practice Information Survey (PPIS) to update the specialty-specific data used to develop practice expense RVUs. This would  increase ophthalmology's practice expense per hour (PE/HR) from $103.28 to $170.08, notes the ASCRS release. Whether or not the pay cuts will actually become final is anyone's guess. "Since far less draconian cuts have been reversed by Congress over the past seven years, and since the current plan in Congress and in the Obama administration is to finalize a healthcare reform package by November, I expect that this issue will be addressed before the draft regulation takes effect," says David C. Harlow, Esq., of The Harlow Group in Newton, Mass. CMS is accepting comments regarding the proposed fee schedule until August 31. Information on how to comment can be found on page 2 of the Federal Register document, available online at http://edocket.access.gpo.gov/2009/pdf/E9-15835.pdf.