CODING Q&A

Ring in the Old, the New — and the Reduced

Ophthalmology — retina in particular — undergoes significant reimbursement changes in 2015.

SUZANNE L. CORCORAN, COE

Just in case 2014 didn’t offer enough challenges to your ophthalmic practice — such as the administrative burdens of the Physician Quality Reporting System and meaningful use — 2015 brings not only a continuation of the “old,” but new challenges as well. You can expect they will have an impact on all aspects of your practice. Retina is hit with some significant reductions. Let’s look at the new year’s changes.

THE BIG QUESTIONS

Q. What changes can we expect for physician reimbursement?

A. Efforts to eliminate the flawed Sustainable Growth Rate (SGR) formula continue. The SGR Repeal and Medicare Provider Payment Modernization Act (H.R. 4015/S.2000), which would repeal the SGR, would also institute a 0.5% update to Medicare physician payments for five years, and preserve fee-for-service payments. The act would also create a new, non-budget-neutral, Merit-Based Incentive Payment System. The bill did not pass in 2014, so the process restarts in 2015.

The Protecting Access to Medicare Act (PAMA) 2015 preserves a 0% physician fee schedule update for Jan. 1 to March 31, 2015. The Nov. 13, 2014, Federal Register included the final rule for the Medicare Physician Fee Schedule (MPFS) and other Medicare Part B payment policies. The conversion factor changes slightly from $35.8228 to $35.8013. If Congress does not intervene prior to April 1, the SGR drops the conversion factor to $28.2239, effective April 1 to Dec. 31, 2015. Relative Value Unit (RVU) changes took place Jan. 1, so the fee schedule for the first quarter of 2015 is not just a continuation of 2014. In addition, CMS corrected an error in the malpractice RVUs, which results in about a 1% to 2% reimbursement reduction for ophthalmology.

The end result? Again, we will have more than one MPFS in 2015. We are expecting a net reduction of 2% to 5% overall for ophthalmology in 2015, not counting a possible SGR cut.

Unfortunately, the big losers are mostly retina:

• Intravitreal injection (67028) is reduced by about 3%

• PPV (67036) is reduced 9%

• PPV with removal of ILM (67042) is reduced 26%

• PPV with endolaser PRP (67040) is reduced 29%, and

• SCODI retina (92134) is reduced 2%.

The comprehensive eye exam for established patients (92014) also took a small hit (only about 1%), but it adds up as this code is billed so often.

Also included in the final rule is a plan to transition away from global surgery packages. Minor surgery 10-day global periods expire in 2017; 90-day global periods expire in 2018. Medically reasonable and necessary visits, both preop and postop, would be billed separately. Ophthalmic specialty societies oppose this approach and are working with CMS to delay implementation until more information is available.

Q. What coding changes affect ophthalmology?

A. The 2015 CPT coding manual contains a number of new codes, revisions and deletions applicable to ophthalmology, although only one, 0380T, is retina-specific. Coverage and payment for Category III codes remain at carrier discretion.

Q. Are there changes to diagnosis codes this year?

A. No; in anticipation of ICD-10 implementation on Oct. 1, 2015, there are no changes.

Q. What about ASC and HOPD reimbursement?

A. For 2015, the ASC conversion factor increases by 1.4% for those centers meeting the quality reporting requirements.

This results in small increases in facility reimbursement.

Various adjustments to hospital reimbursement result in a hospital outpatient department (HOPD) rate increase of 2.3%.

Q. What are Medicare auditors looking at in 2015?

A. The annual publication of the Office of Inspector General (OIG) Work Plan published a series of initiatives that will continue in 2015. While no new initiatives appear pertinent to ophthalmology, the returning targets for scrutiny include:

• Place of service errors

• Payments for drugs

• Ambulatory surgical centers – payment system

• Ophthalmological services – questionable billing during 2012

• Imaging services – payments for practice expense

• Medicare incentive payments for adopting electronic health records

• Anesthesia services – payments for personally performed services

• Payment for compounded drugs under Medicare Part B

• Security of certified electronic health record technology under meaningful use

Total corrections since the Medicare Fee-for-Service Recovery Audit Program began in October 2009 stand at $7.26 billion, including $6.8 billion in overpayments.

Q. Are there changes to PQRS in 2015?

A. The Patient Protection and Affordable Care Act made PQRS mandatory in 2015. Those eligible professionals who did not successfully report PQRS in 2013 will get a reduction off the MPFS in 2015. Providers who were not successful reporters in 2014 will be penalized 2% in 2016. There will be no PQRS bonus payments in 2015.

Q. Did ophthalmologists earn any EHR bonus money?

A. Yes. As of September 2014, the Electronic Health Record Incentive Bonus Program paid out $6.47 billion to eligible providers; $187 million to ophthalmologists and $261 million to optometrists. Requirements going forward continue to challenge practices.

CMS granted a reprieve to providers expected to attest to Stage 2 requirements for 2014, due to a variety of vendor issues and other hang-ups. Most reported Stage 1 objectives and measures for 2014 and will move forward with Stage 2 in 2015. Meaningful use reporting in 2015 requires full-year participation for anyone beyond year one reporting. For those who did not qualify for a hardship exemption or complete their meaningful use attestation for Stage 1 by Oct. 1, 2014, a penalty of 1% off their MPFS applies for 2015.

Q. What changes are taking place for patients?

A. Not many. The Medicare Part B premiums remain $104.90 for most beneficiaries. The Part B deductible also remains at $147. These beneficiary costs are unchanged from 2013 and 2014. RP