What Eye Care Leaders Must Know About the Proposed Physician Fee Schedule for 2016

It’s here: 798 pages containing proposed reimbursement and regulatory changes that will impact your eye care practice’s bottom line in 2016. We’re going to spare you the mind-numbing detail and cut to the chase. Here’s what eye care leaders should be paying attention to during the comment period, which ends September 8, 2015. Expect the final rule by November 1.

Ophthalmic reimbursement will stay flat amidst a 0.5% overall Medicare reimbursement increase in the first MPFS after SGR repeal.

It could be worse: Gastroenterology will take a 5% hit in this first fee schedule after SGR repeal and radiation oncology will take a 3% cut.

It could be better: Pathology gets an 8% hike.

You’ll see 1% reimbursement increases for codes like these:

66821, After cataract laser surgery

67210, Treatment of retinal lesion

92012, Eye exam, established patient (facility)

92014, Eye exam and treatment, established patient, 1 or more visits (non-facility)

And 1% decreases for codes like this:

66984, Cataract surgery with IOL insert, stage 1 (facility)

And no change at all for codes like these:

92012, Eye exam, established patient (non-facility)

92014, Eye exam and treatment, established patient, 1 or more visits (facility)

“Misvalued Codes” The ACA requires CMS to review and reduce the reimbursement for “misvalued codes.” Here are the codes up for reimbursement cuts in the final rule, according to ACRS/ASOA and the proposed MFPS (Table 8, starting at page 75):

92002, Eye exam, new patient

92136, Ophthalmic biometry

92240, Icg angiography

92250, Eye exam with photos

92275, Electroretinography

Cataract Surgery in Your Office? It would be cheaper to provide routine cataract surgeries in surgical suites in your office instead of outpatient facility settings, CMS suggests. Medicare benes would benefit from the convenience factor, and surgeons from more flexible scheduling options, the proposed rule argues. More complicated cases (such as pseudoexfoliation) would still be performed in HOPDs and ASCs. CMS wants comments from ophthalmologists “and other stakeholders” on whether in-office surgical suite cataract surgery is a good idea, as well as input from the RUC on what the RVUs should be.

ASC Impact If you have ownership interest in an ophthalmic ASC, this proposed site change for routine cataract surgeries could hurt your ASC caseload and put you in the red on the ASC front. Cataract surgery with IOL insert, stage one, represents almost 17% of all ASC procedures, not just ophthalmic ASC procedures. Cataract procedures aside, ASC’s will “fare a little better” than HOPD’s under the proposed 2016 OPPS. ASC’s will see a 1.1% increase overall, according to AAPC.

PQRS: New Diabetic Retinopathy Measures Group If you participate in PQRS to avoid Medicare payment cuts, CMS is proposing new diabetic retinopathy measures (Table 28, p. 491 of the proposed rule).

2 New Stark Exceptions The MPFS proposes two new Stark exceptions—one that would allow entities like hospitals to help you out with non-physician practitioner staff expenses and one for timeshare leasing arrangements. So if you’re looking to get some help from a PA, NP, or visiting independent physician, you could be in luck. Over the course of 70 pages, the fee schedule details how these proposed exceptions would work and “clarifies” the existing Stark rule. It’s even more excruciating to read than the rest of the schedule, so I suggest you go here for a good summary.

And a Bigger Question: Do We Need Stark Anyway? Near the end of the Stark musings, CMS proposes some surprising questions, essentially asking if Stark is irrelevant 21st medicine and counterintuitive to coordinated care. Here’s a good summary of CMS’s questions. The agency says it is looking for feedback during the comment period.

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Photo Credit: Jason Sussberg. CC-BY 2.0.

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