Ophthalmology and Optometry Coding Alert

Ophthalmologists will experience a 10 percent hit in RVUs this year.

With every new year, medical practices face changes to their codes, billing procedures, and payments. This year is no exception, with the 2020 Medicare Physician Fee Schedule Final Rule spelling out changes to eye care practices that may not be particularly well received.

Ophthalmologists will be the hardest hit by this year’s fee schedule changes, facing a -10 percent combined impact to relative value charges, and optometrists will see a -5 percent change. Although no single change is responsible for the pay cuts, CMS says, the misvalued code initiative takes some blame for the issues.

“The most widespread specialty impacts of the RVU changes are generally related to the changes to RVUs for specific services resulting from the misvalued code initiative, including RVUs for new and revised codes,” CMS says in the Final Rule. “The estimated impacts for several specialties, including ophthalmology and optometry, reflect decreases in payments relative to payment to other physician specialties as a result of revaluation of individual procedures reviewed by the AMA’s relative value scale update committee (RUC) and CMS.”

E/M Changes to Hit Next Year

If you’re wondering whether the fee schedule made any announcements regarding the big changes to E/M services that CMS had previously proposed, note that those are still scheduled to go into effect on Jan. 1, 2021, and will therefore not affect you in 2020.

However, the 2020 final rule did put an end to CMS’s controversial proposal to blend E/M level payments. As it stood, the proposal to merge E/M levels two through four for both new and established patients and reimburse them at the same rate “would have caused a real issue with medical care, as why would a physician spend the time it takes to perform a 99214 (Office or other outpatient visit …) when they would get reimbursed the same as a 99212,” notes Donelle Holle, RN, a healthcare, coding, and reimbursement consultant in Fort Wayne, Indiana. “The other fear was that providers would try to get to that 99215 without showing medical necessity due to the payment reform.”

But CMS is still going ahead with its decisions to let you use either medical decision-making (MDM) or time to select the level of the outpatient E/M service, to adopt the CPT^® interpretive guidelines for MDM, and to delete E/M code 99201 starting in 2021. This will “bring Medicare in line with what will be in CPT^® in 2021, which should simplify matters for practices as compared to having Medicare-specific rules,” says Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians.

No more 99358-99359: As of January 1, 2021, you will no longer use 99358/+99359 (Prolonged evaluation and management service before and/or after direct patient care …) to report non face-to-face prolonged services, as the codes will be deleted in a dramatic change to the way you will report prolonged services.

Instead, CMS is introducing a new CPT^® code, currently designated with 99XXX (Prolonged office or other outpatient evaluation and management service(s) (beyond the total time of the primary procedure which has been selected using total time), requiring total time with or without direct patient contact beyond the usual service, on the date of the primary service; each 15 minutes (List separately in addition to codes 99205, 99215 for office or other outpatient Evaluation and Management services)). You will use the code “when time is used for code level selection and the time for a level 5 office/outpatient visit (the floor of the level-5 time range) is exceeded by 15 minutes or more on the date of service,” according to CMS.

The good news is that “Medicare using CPT^® codes is always preferable because practices don’t have to vary their reporting by payer,” notes Moore. So, “there should be no problem with the code being adopted by private payers,” agrees Holle.

However, “no longer recognizing 99358/+99359 could be problematic, as it is unclear how these codes as currently described will relate to the revised office/outpatient visit codes when the latter go into effect in 2021,” Moore points out.

Keep an eye on Ophthalmology Coding Alert to stay on top of this topic as more details materialize.

Resource: To read the Federal Register, which contains the 2020 Medicare Physician Fee Schedule Final Rule, visit  www.federalregister.gov/documents/2019/11/15/2019-24086/medicare-program-cy-2020-revisions-to-payment-policies-under-the-physician-fee-schedule-and-other.