Ophthalmology and Optometry Coding Alert

Ophthalmology coders, get ready for another year of nail-biting to find out if your Medicare payments will be slashed.

"The update to the physician fee schedule conversion factor is -- 21.2 percent for CY 2010," notes the 2010 Medicare Physician Fee Schedule Final Rule, printed in the Federal Register that will be published on Nov. 25.

Traditionally, Congress has stepped in to reverse such dramatic cuts before they take place, but unless that happens this year, you'll face a conversion factor of $28.4061 effective Jan. 1, according to calculations in the Federal Register.

Silver lining: Although cuts to certain CPT codes will have a drastic impact on some specialties in 2010 -- like nuclear medicine (18 percent drop in reimbursement) and cardiology (8 percent drop) -- the Centers for Medicare & Medicaid Services (CMS) estimates that ophthalmology practices will experience a five percent raise in total relative value units (RVUs) in 2010 and a 13 percent raise over a four-year period.

Clouds: Even with higher RVU assignments, once CMS applies the new conversion factor, the reimbursement for many frequently performed ophthalmology procedures will plunge next year. For a look at how RVU changes will affect certain high-volume ophthalmology procedures in 2010, see "Prepare for $89 Drop in Cataract Reimbursement Next Year" on page 67.

Good news: Although CMS has proposed halting payment for the consultation codes (99241-99255) in 2010 (see "CMS Proposes Scrapping Consult Code Payment" in Ophthalmology Coding Alert Vol. 12, No. 6), the AMA chose not to delete them,

keeping them in the CPT manual for another year.

"It is important to understand that the consultation codes have not been eliminated; therefore, private payers may still pay for these services," notes Maggie M. Mac, CPC, CEMC, CHC, CMM, ICCE, consulting manager for Pershing, Yoakley, and Associates in Clearwater, Fla. Check with your third-party payers for guidance.

Bad news: Beginning Jan. 1, 2010, CMS will no longer reimburse consultation codes (99241-99245 and 99251-99255) provided to Medicare patients in the outpatient, inpatient, or nursing facility settings, according to the 2010 Medicare Physician fee schedule Final Rule.

"Only CMS has decided to make the codes 'inactive.'" Mac notes. Instead, office visit or hospital visit codes will be utilized.

The inactive status of consult codes for Medicare patients will hurt specialty practices in particular, says Susan Vogelberger, CPC, CPC-H, CPC-I, CMBS, CCP-P, CEO of Healthcare Consulting and Coding Education in Boardman, Ohio.

CMS will raise payment for the other E/M codes to try and offset the consult loss. For instance, you'll see a 7 percent increase for 99214, with physician work RVUs rising to 1.50 from the 2009 rate of 1.42. However, certain specialists still end up losing money.

"I see this step by CMS as a positive change in that compliance with appropriate code selection will be dramatically increased," declares Mac. "CMS has repeatedly been asked to clarify consultation coding over the years."

Consultation definitions can vary widely amongst private payers and CMS, which has further increased the confusion, she notes. "Unfortunately, I've seen too many program safeguard contractors who have performed physician practice reviews and recouped monies based on services not meeting the consultation criteria. Increasing reimbursement to the other E/M services will help offset the financial loss but it will be more comforting to know that this will no longer be a nightmare with coding compliance and recoupments," Mac says.

For more information on Medicare's physician reimbursement plans for next year, read "Payment Policies Under the Physician fee schedule and Other Revisions to Part B for CY 2010" at www.federalregister.gov/OFRUpload/OFRData/2009-26502_PI.pdf.