Ophthalmology and Optometry Coding Alert

Plus — another rate cut is on the horizon.

The Centers for Medicare & Medicaid Services (CMS) issued its Medicare Physician Fee Schedule (MPFS) final rule on Nov. 1, 2024. While the 3,088-page document contains substantial changes to telemedicine and strategies for improving care for specific health and social conditions, optometry and ophthalmology practices will also see changes when the calendar flips to 2025.

Read on to find out what CMS has in store for optometry and ophthalmology practices.

Separate Optometry and Ophthalmology Specialties Once Again

CMS is establishing a new specialty measure set for optometry for the calendar year (CY) 2025 performance period and the 2027 Merit-Based Incentive Payment System (MIPS) payment year and future years.

In the 2023 MPFS final rule, the agency combined optometry and ophthalmology into a single specialty set. However, interested stakeholders proposed separating the two specialties for CY 2025, citing the different procedures performed in each specialty. “We simultaneously proposed to create a separate optometry specialty set with a more limited number of quality measures based on differences in scope of practice to ophthalmology,” CMS wrote in the 2025 MPFS final rule.

Under final rule’s Table B.29, CMS lists several measures and the reasons for inclusion related to the new optometry specialty set. According to the agency, “the optometry specialty set takes additional criteria into consideration, which includes, but is not limited to, whether a measure reflects current clinical guidelines, and the coding of the measure includes relevant clinician types.”

For example, CMS added a diabetic retinopathy measure covering communication with the patient’s primary care clinician to the optometry specialty set and significantly revised the measure from previous years.

Observe a New Ophthalmology MVP

CMS also finalized several updates to the MIPS Value Pathways (MVPs). Among the updates are six new MVPs for ophthalmology, dermatology, gastroenterology, pulmonology, urology, and surgical care.

“CMS received several comments noting the administrative burden that remains in the reporting of MVPs. Regardless, CMS reasserted plans to make MVPs mandatory. The timeline regarding this will be set in future rulemaking,” wrote Sarah Starling Crossan, public affairs advisor for Holland & Knight, in online analysis.

According to the final rule, the new MVPs are relevant and meaningful to MIPS-eligible clinicians. The new ophthalmology-specific MVP is Complete Ophthalmologic Care, which “focuses on assessing meaningful outcomes in cataract, glaucoma, retinal detachment, and broadly applicable ocular care,” according to the agency. This MVP applies to optometry and ophthalmology healthcare providers.

Prepare for a Possible Reimbursement Reduction in 2025

In the CY 2025 MPFS final rule, CMS announced a conversion factor (CF) of $32.35, which marks a fifth straight year of decreased conversion factors. The 2025 CF is a 2.83 percent reduction from the 2024 MPFS CF of $33.29.

Ophthalmology and optometry specialties will feel the negative effects of the CF decrease as well. The MPFS final rule shows the combined impact on each specialty, and while the overall financial effect varies depending on several factors, the annual Consolidation Appropriations Act (CAA) adjustment isn’t considered in the combined impact. That is because the current CAA is set to expire on Dec. 31, 2024. If Congress doesn’t move to enact a substantial adjustment, healthcare specialties, including ophthalmology and optometry, will face a year of operating costs outpacing reimbursement.

“The estimated impacts for several specialties, including … ophthalmology and optometry …, reflect decreases in payments relative to payment to other specialties, largely resulting from the redistributive effects of the implementation of the Year 4 update to clinical labor pricing and/or the proposed adjustments to transfer of post-operative care for global surgical procedures,” CMS wrote in the final rule.

At the same time, the Medicare Economic Index (MEI), which is the annual practice cost inflation measurement that is used to determine appropriate Medicare reimbursement for physicians, carries a 3.5 percent increase for 2025 according to the final rule.

“To put it bluntly, Medicare plans to pay us less while costs go up. You don’t have to be an economist to know that is an unsustainable trend, though one that has been going on for decades,” said Bruce A. Scott, MD, president of the AMA, in a press release.

Resource: Read the 2025 MPFS final rule in the Federal Register when it’s published on Dec. 9, 2024.