The American Medical Association recently released the Current Procedural Terminology (CPT) code set for 2024.¹ As usual, there are important coding changes, as well as changes to Medicare reimbursement, that retina practices need to be aware of in the new year. 

Q. What are the coding changes?

A. There are no code changes for evaluation and management (E/M) codes, but there are changes to the descriptions. The decision of which E/M code to bill can be determined either by medical decision-making (MDM) or by time. For ophthalmologists, most visits are coded based on MDM, but time is a factor in some cases. In years past, CPT simply assigned times to each E/M code. Now, the description has been expanded to include total physician time spent on the date of the encounter. This is not a coding or policy change, but the CPT definitions have changed the coding ranges and only listed the minimum. The descriptions now read: “When using total time on the date of the encounter for code selections, XX minutes must be met or exceeded.” The amount of time varies, of course, according to code.

There is only 1 new Category I CPT code for ophthalmology in 2024: “67516 Suprachoroidal space injection of pharmacologic agent (separate procedure).” This replaces the Category III code “0465T Suprachoroidal injection of a pharmacologic agent (does not include supply of medication).” The new Category III code that is pertinent to ophthalmology is “0810T Subretinal injection of a pharmacologic agent, including vitrectomy and 1 or more retinotomies. Effective: January 1, 2024.”

Q. What’s happening with physician reimbursement?

A. The 2024 Medicare Physician Fee Schedule (MPFS) Final Rule was released on November 2, 2023, and published in the Federal Register on November 16, 2023. The 2024 MPFS conversion factor for 2024 is $32.7442, down 3.36% from $33.89 in 2023. This reflects the 0% update adjustment factor that was part of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA); a 1.25% update provided under the Consolidated Appropriations Act, 2023 (CAA), and  budget neutrality adjustment of -2.18%; this is primarily due to the implementation of the complex care add-on code G2211. The Centers for Medicare and Medicaid Services (CMS) estimated the financial impact by specialty in the Final Rule. According to CMS, ophthalmology will see an overall reduction of about 1%. 

Common Medicare Payments 2023 vs 2024

Q. What is the complex care add-on code?

A. New HCPCS code G2211 is defined as “Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient’s single, serious condition of a complex condition.”² So far, CMS has not issued instructions for use of this code. However, the CMS website includes a listing of pertinent “practitioner primary care specialties,” and it does not include ophthalmology (or optometry). At this time, it does not appear that the new code will be helpful to ophthalmology in recovering any of the MPFS decrease.² RP

Brandy H. Sperry, COMT, COE, CPC, CPMA, is an associate consultant with Corcoran Consulting Group (CCG) in San Bernardino, California, which specializes in coding and reimbursement issues for ophthalmic practices. Reach her at bsperry@corcoranccg.com.

 References

American Medical Association. AMA releases the CPT 2024 code set. September 8, 2023. Accessed November 24, 2023. https://www.ama-assn.org/press-center/press-releases/ama-releases-cpt-2024-code-set

Centers for Medicare and Medicaid Services. Evaluation of the primary care first model: first annual report. December 2022. Accessed November 24, 2023. https://www.cms.gov/priorities/innovation/data-and-reports/2022/pcf-first-eval-rpt