Ophthalmology and Optometry Coding Alert

One ophthalmologist in our sampling would lose $39,000 a year under the new proposal.

Although eye care practices have the option of reporting either ophthalmological services codes or E/M codes for their patient encounters, many ophthalmologists and optometrists bill the E/M codes fairly often. But how those charges are documented and billed could change dramatically next year, as CMS is considering major changes to the 99201-99215 code set.

Here’s the scoop: CMS released its proposed Medicare Physician Fee Schedule (MPFS) for 2019 on July 12, and it includes what the agency is calling “historic” E/M documentation changes to the outpatient office visit codes (99202-99215). Those changes include the following:

• Use medical decision-making or time for outpatient E/M versus the current guidelines.
• Give physicians the option of using time as a factor even if counseling or care coordination are part of the medical equation.
• Put re-documenting aside and let providers “focus their documentation on what has changed since the last visit or on pertinent items that have not changed.”
• Give practitioners the option of accepting data plugged in by staff instead of timely re-entering.

To go with these documentation and code selection changes, CMS is proposing a “new, single blended payment rates for new and established patients for office/outpatient E/M level 2 through 5 visits and a series of add-on codes to reflect resources involved in furnishing primary care and non-procedural specialty generally recognized services,” the agency said in a Fact Sheet about the change. The payment levels are proposed as follows:

• 99212-99215: $93 for each of these codes
• 99202-99205: $135 for each of these codes.

Translation: Under the proposal, payments for level four and five codes would go down, while you’d see an increase in pay for level two and three codes. Practices that report a lot of level five codes would be likely to lose money, but some practices would see gains, says Cyndee Weston, CPC, CMC, CMRS,  executive director of the American Medical Billing Association (AMBA) in Davis, Oklahoma.

Check Out These 3 Ophthalmology-Specific Examples of How Pay Could Change

To determine the impact that this change might have on eye care practices, Ophthalmology and Optometry Coding Alert reviewed the utilization data for three different eye care physicians and calculated how it would impact each of them.

These calculations assume that the eye care specialists will earn $93 for each of the following codes under the proposal, and that they currently bring in the following average reimbursement for 99212-99215:

• 99212: $45
• 99213: $75
• 99214: $109
• 99215: $148

Impact to Practice 1: Ophthalmologist in Central North Carolina:

• 99212: Billed 32 times in one year – worth $1,440 today, worth $2,976 under proposal
• 99213: Billed 119 times in one year – worth $8,925 today, worth $11,067 under proposal
• 99214: Billed 181 times in one year – worth $19,729 today, worth $16,833 under proposal
• 99215: Billed 57 times in one year – worth $8,436 today, worth $5,301 under proposal

Total Difference: This physician earned $38,530 for these four codes under today’s payment structure, and would earn $36,177 under the proposal. This physician would see $2,353 less pay under the proposal for these four codes.

Impact to Practice 2: Ophthalmologist in South Florida:

• 99212: Billed 16 times in one year – worth $720 today, worth $1,488 under proposal
• 99213: Billed 24 times in one year – worth $1,800 today, worth $2,232 under proposal
• 99214: Billed 2,255 times in one year – worth $245,795 today, worth $209,715 under proposal
• 99215: Billed 77 times in one year – worth $11,396 today, worth $7,161 under proposal

Total Difference: This physician earned $259,711 for these four codes under today’s payment structure, and would earn $220,596 under the proposal. This doctor would see $39,115 less pay under the proposal for these four codes.

Impact to Practice 3: Ophthalmologist in Michigan:

• 99212: Billed 34 times in one year – worth $1,530 today, worth $3,162 under proposal
• 99213: Billed 89 times in one year – worth $6,675 today, worth $8,277 under proposal
• 99214: Billed 109 times in one year – worth $11,881 today, worth $10,137 under proposal
• 99215: Billed 12 times in one year – worth $1,776 today, worth $1,116 under proposal

Total Difference: This physician earned $21,862 for these four codes under today’s payment structure, and would earn $22,692 under the proposal. This ophthalmologist would see $830 more pay under the proposal for these four codes.

Bottom line: Two of these three physicians would lose money under the proposal versus what they earn now. Of course, this doesn’t mean your ophthalmologist will also face the same fate, but it does suggest that eye care practices should keep a close eye on the proposed changes. If you know how frequently you reported each of these codes, you can perform a similar calculation to determine how the change would affect you.

Would Documentation Guidelines Hurt You?

Keep in mind that if the proposal is finalized, you would have to be ready to code your charts based on new criteria. For instance, if the code level ends up being based on medical decision-making (MDM) rather than the current method of history, medical decision-making, and exam, there could be a learning curve for some practices, says Michael Granovsky, MD, FACEP, CPC,  President of LogixHealth, a national coding and billing company based in Bedford Massachusetts. “MDM can be subjective – the risk table is not black and white unless you’re using the intervention column, which is probably historically the least relevant.”

Certainly, the inclusion of a suggested E/M change in the fee schedule proposal doesn’t mean that a change will actually happen. Keep an eye on Ophthalmology and Optometry Coding Alert for all the latest on whether CMS moves toward finalizing these proposals.

Resource: For a closer look at the MPFS proposed rule for CY 2019, visit https://s3.amazonaws.com/public-inspection.federalregister.gov/2018-14985.pdf.