From the American Academy of Ophthalmology

Ophthalmologists to Face Significant Payment Reductions

Today, the Centers for Medicare & Medicaid Services released its Medicare Physician Fee Schedule final rule for 2015. It is important to note that unless Congress acts to fix the flawed sustainable growth rate formula, effective April 1, 2015, the conversion factor will fall to $28.2239 from the current rate of $38.8013. The Academy will continue to advocate for Congress to repeal the SGR. Below is a list of rulings that will significantly influence the practice of ophthalmology.

Dramatic change: CMS finalizes plan to eliminate global surgery periods
CMS has finalized its rule to eliminate 10- and 90-day global surgical packages over the next few years, despite significant opposition from the Academy and other surgical groups. CMS has ruled that it will:

• Drop postoperative care from surgical codes beginning in 2019.
• Eliminate post-op visits from 10-day global codes beginning in 2017 and then from 90-day global codes in 2018.
• Work with physicians and the AMA Relative-value Update Committee to determine new work values for surgery services as well as payment for pre- and post-operative care in the interim.

Glaucoma and Vitrectomy Reductions
CMS accepted the RUC approved values for the surgical procedures surveyed by the Academy for 2015. This action will bring decreases for pars plana vitrectomy procedures (67036-67043) as well as for glaucoma shunt services that were previously billed with an additional surgical graft (66180, 66185). Specifically, retina and glaucoma subspecialists will experience:

• Reductions of 7 to 25 percent resulting from decreases in reported work time for the vitrectomy codes in 2015.
• Approximately 30 percent lower average payments in 2015 for glaucoma shunt services when placing the graft at the time of a tube shunt. This is due to a CMS request that the grafting work be bundled into the aqueous shunt codes 66180 and 66185.

CMS cuts overpaid malpractice values
CMS will reduce Medicare payment to ophthalmologists, following an error that CMS made five years ago in calculating revised malpractice relative value units. The agency is recalculating the rates for ophthalmology using updated malpractice premium data.  Such data was inadvertently excluded during the 2010 update. This change means that:

• Ophthalmologists will receive a 2 percent decrease in overall Medicare payments caused primarily by the malpractice change. The Academy advocated that the malpractice reduction be phased in; however, CMS declined our proposal.
• CPT 66984 cataract with IOL will receive a 4 percent reduction in 2015.  Many high volume ophthalmic surgical codes will receive similar decreases.

CMS compromises on value-based modifier penalty
Heeding the Academy’s opposition to the value-based modifier penalty, CMS finalized a compromise to keep the value-based modifier penalty at 2 percent for solo practitioners and groups with fewer than 10 providers, but increase  the penalty to 4 percent for group practices with 10 or more providers. All physicians who participate in fee-for-service Medicare, including solo practitioners, will be subject to the value-based modifier 2017, calculated using cost and quality data collected in 2015. CMS will not apply the value-based modifier to non-physician eligible professionals including nurse practitioners and physician assistants in 2017; however, it will apply to optometrists.

Implementation of the value-based modifier is based on participation in the Physician Quality Reporting System.

• Successful participation in PQRS in 2015 will exempt solo practitioners and physician practices with fewer than 10 providers including optometrists from any negative payment adjustments.
• Failing to participate in PQRS in 2015 will result in a penalty from the PQRS program in addition to a penalty from the value-based modifier program.
• Practices with fewer than 10 providers and solo practitioners who do not successfully participate in PQRS in 2015 will receive automatic payment reductions of 2 percent in 2017 from the value-based modifier, while practices with 10 or more providers will receive automatic payment reductions of 4 percent in 2017 from the value-based modifier.

PQRS requirements to avoid penalty to be greater in 2015
Despite the Academy’s efforts, CMS finalized its proposal to increase the requirements under PQRS to avoid associated penalties. CMS ruled:

• Not to eliminate the claims reporting option in 2015 for most eye care measures. Strong advocacy efforts by the Academy helped to maintain this option for ophthalmologists.
• To increase the number of measures that physicians must report in 2015 from three to nine in order to avoid the two percent penalty in 2017.
• To require physicians to report on at least one crosscutting or primary care measure.
• To increase the number of measures in the cataract measures group from four measures to eight, which must be reported for 20 patients.
• To keep the two ophthalmology measures related to Age-Related Macular Degeneration will remain in the program, as a result of the Academy’s pressure:
  • Dilated Macular Examination measure, and
  • Counseling on Antioxidant Supplement.
• To include two  new ophthalmology cataract-related measures:
  • Unplanned vitrectomy following cataract surgery, and
  • Percentage of time the final refraction is +/- 1D of the target refraction.
• To include two new ophthalmology retina-related measures:
  • Retinal detachment repair success rate (flat retina 6 months post-surgery)
  • Retinal detachment surgery success rate (requiring only one  surgery)
• To publicly report 2015 physician-level quality performance data on Physician Compare in 2016.

Physicians will have the option to continue to participate in PQRS through claims and qualified registry reporting, direct electronic health record submission, or through participation in a qualified clinical data registry such as the Academy’s IRIS™ Registry.

IRIS Registry participants will have access to additional ophthalmology specific measures that are not available through other PQRS reporting mechanisms. Like all eligible professionals, Qualified Clinical Data Registry participants must comply with the nine-measure minimum, and additionally report two outcomes measures. IRIS will report on behalf of the provider, and participants should not experience additional reporting burdens. Because of the Academy’s opposition, CMS agreed to delay the public reporting of individual physician or practice level performance data on first year QCDR measures until the measures have been reported for at least one year.

Ambulatory Surgery Center payments increases slightly in 2015
In the final Ambulatory Surgery Center rule also released today, CMS has ruled that:

• ASCs that satisfactorily report on quality measures will see a 2015 Conversion Factor of 44.071, up from 43.471. Payments to ASCs that fail to meet quality reporting program requirements will be decreased to 43.202.
• Despite the Academy’s urging to completely remove the problematic cataract ASC-11 measure from the ASC quality reporting system program, CMS finalized its policy to make reporting of this measure voluntary. CMS will not subject ACSs to payment reductions with respect to this measure. The Academy strongly advised that this measure, which requires facilities to report pre- and post-operative patient visual function, is not appropriate for the ASC setting.

The Academy is continuing its analysis of today’s announcement. We will provide further information in the weeks ahead in Washington Report Express as well as on the Academy’s website. If you have questions, or would like additional information, contact the Academy’s Governmental Affairs Office at 202.737.6662