Ophthalmology and Optometry Coding Alert

CMS is considering in-office cataract surgery, but CF will likely decrease.

Physicians may be facing more payment cuts in the coming year. But on the bright side, enhancements in health equity and expanded access to first-rate comprehensive healthcare for all are on the horizon.

Context: On July 7, the Centers for Medicare & Medicaid Services (CMS) unveiled the calendar year (CY) 2023 Medicare Physician Fee Schedule (MPFS) proposed rule. It’s chock full of proposed billing revisions and payment provisions, which include updates surrounding key issues like evaluation and management (E/M) services, chronic care management (CCM), and telehealth.

Here’s a glimpse of five proposals you should keep an eye on, as they’ll likely impact your Medicare policies and reimbursement.

1. Anticipate Additional E/M Services Updates

To better align with previous changes made to office/outpatient E/M service codes in the CY 2021 MPFS final rule, CMS proposes to push forward with AMA CPT^® Editorial Panel-approved revisions to coding and guidelines for “Other E/M visits” — hospital inpatient, hospital observation, emergency department (ED), nursing facility, home or residence services, and cognitive impairment assessment — effective Jan. 1, 2023.

In a nutshell, the changes that CMS plans to accept for “Other E/M visits” include adopting new code descriptors/definitions and utilizing the same interpretive guideline revisions for levels of medical decision making (MDM) as CPT^® adopted in 2021 for office/outpatient E/M services. This means nixing history and exam and instead using time or MDM to determine code level for the majority of the code sets. These updates will bring Medicare in line with the CPT^® revisions for the services.

2. Recognize Telehealth Policymaking Continues to Evolve

The rule, if enacted as proposed, will extend coverage of the temporary codes CMS didn’t add to its Medicare telehealth services list under Categories I, II, or III during the COVID-19 public health emergency (PHE). Reflecting legislation passed last year, these policies will remain in place until 151 days following the conclusion of the PHE, which was extended to Oct. 15, 2022. (See aspr.hhs.gov/legal/PHE/ Pages/covid19-15jul2022.aspx)

Of interest to eye care practices, the agency proposes maintaining CPT^® 92002 (Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; intermediate, new patient) and 92004 (... comprehensive, new patient, 1 or more visits) on the list through 2023; however, CMS does not intend to permanently include these codes on the telehealth covered services list. Other proposals to watch out for are the creation of three new permanent telehealth codes for prolonged E/M services, discontinuation of virtual direct supervision, and the addition of 54 codes to the Category III telehealth list.

After the 151-day post-PHE extension period, CMS proposes:

• Removing many of the services temporarily available as telehealth services during the PHE, including audio-only services.
• Assigning telephone E/M visit codes (99441, 99442, 99443) a “bundled” status and posting RUC-recommended relative value units (RVUs) for these codes.
• Requiring the appropriate place of service (POS) indicator to be included on the claim, rather than modifier 95 (Synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system).

Ultimately, the feds are trying to ensure a smooth transition after the end of the PHE and prepare Medicare clinicians for a post-COVID landscape.

3. Expect RVU Changes for Ophthalmic Procedures

CMS is proposing to accept both the Relative Value Scale Update Committee (RUC)-recommended RVU of 0.71 and practice expense (PE) for orthoptics CPT^® code 92065, as well as the recommended work RVU of 0.40 and PE for the anterior segment imaging CPT^® code 92287.

Alternatively, the agency is proposing to reject the RUC-recommended RVU of 0.14 for the dark eye adaptation CPT^® code 92284, stating the work value was inaccurate, as the procedure is usually completed during an E/M visit. Instead, CMS proposes a physician work value of 0.00 for 92284, which is comparable to other “ophthalmic screening tests,” such as 99172 (Visual function screening … bilateral quantitative determination of visual acuity, ocular alignment, color vision by pseudoisochromatic plates, and field of vision …) and 99173 (Screening test of visual acuity, quantitative, bilateral).

4. Watch out, Cataract, Retinal Procedures May Be on the Move

In response to a request to establish non-facility values for certain cataract and retinal surgery codes, CMS is asking for feedback on whether to pursue the development of valuation of the cataract and vitrectomy codes in the office setting. Specifically, the agency is seeking comment on:

• The merits of continuing to value these codes only in the facility setting, as opposed to also establishing non-facility values for these cataract and retinal surgery codes.
• Safety considerations for these codes in the non-facility setting.
• Whether these codes are potentially misvalued.

According to the proposed rule, it’s been suggested that these procedures can be properly performed in the office safely and effectively and that expanding to the non-facility setting would help to relieve the backlog for these services.

5. Know Physician Groups Claim Patient Care Is Under Assault

Lastly, the feds are proposing a $1.53 decrease in the conversion factor (CF), resulting in a CY 2023 CF of $33.08, slashing Medicare payment rates by 4.42 percent. This negative adjustment is due in part to the expiration of a 3 percent payment increase provided in CY 2022 by Congress and changes to E/M codes. Also contributing to the drop in next year’s rate are budget neutrality adjustments that require a statutory update of 0 percent to the CF for 2023 to account for changes in RVUs.

Industry leaders across specialties, including ophthalmology, are concerned about the across-the-board reduction in payment rates. “The cost of running a medical practice has increased 39in the past twenty years. When adjusted for inflation, the impact is a decline in value of Medicare physician payments of 28%,” George Williams, MD, American Academy of Ophthalmology senior secretary for advocacy, said in a statement. “On top of jeopardizing patients’ access to care, the proposed cuts further exacerbate the difficult operating environment surgical practices already face and the people that are affected most are our patients.”

Doug Rhee, MD, American Society of Cataract and Refractive Surgery president, also weighed in on the announcement.

“Annual cuts to reimbursement for surgical care imperils access for seniors to medically necessary and sight-saving and sight-restoring therapies,” Rhee said in a statement. “2.3 million Americans last year alone depended on Medicare to receive cataract surgery. Unfortunately, CMS’ proposed Medicare Physician Fee Schedule for 2023 poses an even greater risk than in years past to patient access to these and other life-altering interventions.”

According to American College of Surgeons Executive Director Patricia Turner, MD, MBA, FACS, each year, CMS proposes cuts that put access to critical procedures at risk for millions of patients — often the very patients who are most in need of care.

“Today’s proposed rule underscores the continued disinvestment in patient care, and the Surgical Care Coalition urges Congress to immediately stop these cuts to protect patients and work toward finding a long-term solution that promotes quality care and investment,” Turner said in a release on the proposed rule.

Comments: To offer CMS your two cents on the rule and CF proposals, submit your comments by Sept. 6, 2022, at www.regulations.gov/document/CMS-2022-0113-0001.

Resource: Review the CY 2023 MPFS proposals at public-inspection.federalregister.gov/2022-14562.pdf.