In the News

2009 MEDICARE UPDATE

Fee Schedule Changes
The Medicare Physician Fee Schedule increased payment rates for physician services by 1.1 percent in 2009. The budget neutrality adjustor was shifted from the physician work values which resulted in higher reimbursements despite a decrease in the 2009 conversion factor. The conversion factor for 1009 is $36.0666.

Other provisions of the fee schedule final rule include:

Continuation of the work Geographic Practice Cost Indices (GPCIs) to be at the 1.000 floor (Alaska remains at 1.500). This allows better reimbursement for those providers in payment localities where the GPCI goes below 1.000.
While Medicare enrollment applications are being processed, practices will now only be able to bill for 30 days prior to the later of (1) the date of filing, or (2) the date an enrolled provider first started furnished services in the new practice.
Suspended requirement that physicians offices had to enroll in Medicare as an independent diagnostic testing facility (IDTFs).
Requires providers and organizations to notify Medicare of a change in ownership, final adverse action, or change of location within 30 days of the reportable event.

PQRI
CMS implemented a 2 percent bonus incentive for physicians who participate in the Physician Quality Reporting Initiative (PQRI) program. Three new measures were added this year for ophthalmology for cataracts, macular degeneration, and glaucoma.
E-Prescribing
The final rule also implemented a five-year program of a 2 percent bonus incentive for e-prescribing and extends the current e-prescribing fax exemption until January 1, 2012. Practices that have e-prescribing software will not be penalized under the incentive program if local pharmacies cannot accept electronic submissions.

Eligibility for the e-prescribing bonus will be tied to a threshold of 10 percent of all allowed office visits. To be eligible, providers must report the quality measure on at least 50 percent of applicable cases during the reporting year. Both the AAO (www.aao.org), and ASCRS (www.ascrs.org) have information on their websites regarding e-prescribing specifics. The e-prescribing rules can also be found on the CMS website at www.cms.hhs.gov.

ASC Payment Changes
In 2009, the ASC is in its second year of a 4-year payment transition which means reimbursement will be based on a 50/50 blend of the 2007 ASC payment rages and 65% of the hospital outpatient department (HOPD) rates. The 2009 ASC conversion factor is $41.393.

Three new Category III CPT codes were added to the ASC list for ophthalmology:

0190T – Placement of intraocular radiation source applicator
0191T – Insertion of anterior segment aqueous drainage device, without extraocular reservoir; internal approach
1092T – Insertion of anterior segment aqueous drainage device, without extraocular reservoir; external approach

CPT/HCPCS Code
There are two new CPT codes affecting ophthalmology in 2009:

65756 – Endothelial Keratoplasty
+65757 – Backbench preparation of corneal tissue

Code 65757 is an adjunct code that is paid by Medicare to the physician. There is no ASC facility fee payment for code 65757 since it is a “professional” service.

There are several new Category III CPT codes for 2009:

0186T – Suprachoroidal drug delivery system
1087T – SCODI, unilateral, anterior segment scanning
0191T – Mini-express shunt without external reservoir, internal approach
0192T – Mini-express shunt, external approach
0198T – Ocular Blood Flow analyzer

There is a new HCPCS code for Triesence, code J3300 (1mg). This code is not considered a pass-through drug in the ASC.

ICD-9-CM Diagnosis Codes

249.0 – 249.9 – New diagnosis codes to identify complications associated with secondary diabetes
339 – Other headache syndromes
362 – Other proliferative retinopathy
372 – Disorders of conjunctiva

More details on the 2009 Medicare Updates can be found in our newsletter, The Messenger, Volume 1, Issue6, 2008.

2009 OIG WORK PLAN

The 2009 Office of Inspector General (OIG) Work Plan highlights issues the OIG feels are worth attention in the coming year. Some of the issues affecting ophthalmology in 2009 are:

Place of Service Errors. OIG to determine if correct place of service is properly billed when performed in an ASC or outpatient department of hospital.
Evaluation and Management Services During Global Fee Period. OIG looking to see if separate payments were made for office visits during the global fee period of surgery and if the number of office visits provided has changed.
Medicare Payments for Selected Physicians. OIG reviewing the appropriateness of Medicare Part B payments for selected physician services including surgery, consultations, home, office and institutional calls. OIG wants to make sure these services were documented and performed in accordance with Medicare requirements.
Incident To Services. The OIG will again review “incident to” services provided by allied health personnel to make sure medical necessity, quality of care, and proper documentation is being maintained.
Ultrasound Services. The OIG will review services and billing patterns in areas with high utilization of ultrasound service paid under Medicare to make sure the services are medically necessary.
Physician Reassignment of Benefits. The OIG will review the extent to which Medicare physicians reassign their benefits to other entities.
Payments for Unlisted Procedure Codes. The OIG plans to review the accuracy of Medicare payments for services billed using unlisted procedure codes. Claims will be reviewed to make sure the services were eligible for Medicare payment.
Modifier –GY. The OIG will examine patterns and trends for providers who excessively use modifier –GY. This modifier is used to report services that are statutorily excluded from Medicare coverage or do not meet the definition of a Medicare covered service.
Review of DME Claims with Modifiers. The OIG will review DME claims to look at the use of modifiers for DME supplies to make sure the services are documented as medically necessary. Optical shops use the –KX modifier to bill Medicare for medically necessary optical services ordered by the physician but many not otherwise be covered.

More details on these OIG issues and ways to avoid scrutiny can be found in our newsletter, The Messenger, Volume 2, Issue1, 2009.

ADVANCED BENEFICIARY NOTICE

On March 3, 2008, CMS implemented a revised Advance Beneficiary Notice (ABN). This form will replace the existing ABN (CMS-R-131G) and the laboratory ABN. Providers will have until September 1, 2008, to start using the new ABN.

In the past, an ABN was only used for services that might be considered “not medically necessary.” The revised version of the ABN may now be used to provide notification of financial liability for services that are excluded from Medicare coverage. CMS believes the new version of the ABN should eliminate any widespread need for the Notice of Exclusion from Medicare Benefits (NEMB). Since CMS did not specifically state that the NEMB was being discontinued, you might want to consider continuing to use the NEMB for premium IOL services. We believe the NEMB rather than the ABN would be less confusing for the patient in these cases.

ABNs can be customized somewhat to include clinic name and additional information about the service rendered. The ABN can only be reproduced on a single page, and the page may be either letter or legal size. Entries in the blanks must be typed or hand-written but large enough (e.g., 12-point font or 10-point font for detailed information) to allow ease in reading. If the patient’s signature cannot be read, there must also be a printed annotation of the signature.

All providers and supplies must be using the new ABN no later than September 1, 2008. Detailed instructions and the new ABN form can be downloaded from the CMS Beneficiary Notice Initiative web page at www.cms.hhs.gov/bni.

CONSULTATIONS

In order to bill a consultation, the referring doctor must be asking for the opinion or advice of the consultant on the treatment of his/her patient for a particular condition. When the optometrist or non-surgical ophthalmologist merely sends the patient for cataract surgery, an opinion is not sought, and this would be considered a transfer of care. These visits should be billed as new or established patient visits, not consultations.
However, when the referring doctor requests an opinion as to whether or not the patient is a candidate for surgery, and the patient’s total ocular health and general well being is evaluated, this would, in our opinion, be considered a consultation, not a transfer of care. A letter (or report of recommendations) must be sent back to the referring doctor addressing the request for the consultation and any other issues of concern. This would be true whether or not the consultant determined surgery was needed at that time, or the patient was returned for follow-up until such time as surgery is indicated.

Don’t forget that the request to furnish an opinion or advice must be documented in the Subjective entry of the patient chart. This can be in the form of a phone call from the referring doctor, a written request, or the patient can be the source delivering the request for the consultation. If the patient is the source, then we recommend calling the referring doctor’s office to confirm the request and documenting that phone call in the Subjective entry as well.

See Volume 1, Issue 3, 2008, of our newsletter The Messenger, for additional information on consultations and a consultation case scenario.

PREMIUM IOLs

Physicians may now bill the patient using code V2787 for the additional work involved in implanting astigmatism-correcting intraocular lenses (IOLs) performed in conjunction with conventional cataract surgery. When implanting presbyopia-correcting IOLs, use code V2788. Bill Medicare for the conventional cataract surgery as usual and bill the patient for the extra work and time involved in implanting the premium IOLs.
The ambulatory surgery center or hospital may bill the patient for the extra work involved and/or the cost differential in these premium lenses and the $150 already included in the facility fee for a conventional IOL. Medicare is billed for the conventional cataract surgery which includes payment for the conventional IOL. Bill the patient code V2787 or V2788 as above.

Remember, you are not required to bill Medicare for these excluded services unless the patient asks you to do so for a secondary payer denial.

MEETINGS & LECTURES

Jules Stein Eye Institute & ASCRS Joint Symposium, February 5-8, 2009, Los Angeles, California. Speaker: Heather B. Freeland
Caribbean Eye Meeting (ACES/SEE), February 6-10, 2009, Montego Bay, Jamaica. Speaker: E. Ann Rose
ASOA Web Seminar/2009 Coding Update, February 19, 2009. Speaker: E. Ann Rose
ASCRS-ASOA Symposium & Congress, April 3-8. 2009, San Francisco, California. Speaker: E. Ann Rose
ASCRS-ASOA Symposium & Congress, April 3-8. 2009, San Francisco, California. Speaker: Heather B. Freeland
ASCRS-ASOA Technicians and Nurses Program – JCAHPO, April 3-8, San Francisco, California. Speaker: E. Ann Rose
ASCRS-ASOA Technicians and Nurses Program – JCAHPO, April 3-8, San Francisco, California. Speaker: Heather B. Freeland
National Medical Association, July 25,-29, 2009, Las Vegas, NV. Speaker: E. Ann Rose
Alcon/ASOA Ophthalmic Symposium, August 29, 2009, San Antonio, Texas. Speaker: E. Ann Rose

Please contact us or call (800) 720-9667 for additional information regarding the above lectures and meetings