In the News
2011 MEDICARE UPDATE
Physician Fee Schedule
The impending 24.9 percent reduction in physician fees for 2011 was averted by yet another 12-month Medicare physician fee fix. Medical societies continue to plead with CMS to solve the flawed Sustainable Growth Rate (SGR) used to calculate physician reimbursement and stress the urgency for fair Medicare payments and stability in physician fees. The 2011 Conversion Factor is $25.52.
ASC Fee Schedule
Since January 1, 2008, ASCs have been paid under a revised ASC payment system that aligns payment in ASCs and hospital outpatient settings and extends payment to more surgical services in ASCs than under the prior payment system. There are approximately 5,000 Medicare-participating ASCs. To minimize the impact of the revised payment system, the ASC payment rates calculated under the new rate-setting methodology were phased in over four years. CY 2011 is the first year of the fully-implemented payment rates based on the ASC standard rate setting methodology under the revised ASC payment system.
In general, the revised ASC payment rate for a covered surgical procedure is based on the relative payment weights for the same procedure under the Outpatient Prospective Payment System (OPPS).
PQRS
The fee schedule final rule continues the incentive payments for the Physician Quality Reporting Initiative now referred to as Physician Quality Reporting System (PQRS). CMS will gradually make the name change in their publications and on their website. The PQRS incentives include:
- Successful PQRS reporters will earn a 1.0 percent incentive payment in 2011.
- Ophthalmologists must report on at least three measures at least 50 percent of the time. This is an increase from the 80 percent requirement in 2010.
- Eligible professionals can report on PQRS for either a full year (January 1 through December 31), or a half year (July 1 through December 31).
- Physicians can choose between claims based or registry based reporting. Registry reporting will continue to require 80 percent reporting.
- Group practices with fewer than 200 eligible professionals will now be able to participate in the PQRS group practice reporting option.
- Incentive payments for years 2012 through 2014 will be extended by providing an incentive payment of 0.5 percent of the physician’s estimated total allowed charges during the reporting period.
- In 2015, a 1.5 percent PQRS payment penalty will be applied to physicians and group practices that do not satisfactorily report data on quality measures.
- In 2016, this penalty will increase to 2.0 percent.
E-Prescribing
In 2011, Group practices with fewer than 200 eligible professionals (EPs) are able to participate in the e-Rx Incentive Program. The e-Rx incentives include:
- Eligible professionals who are successful electronic prescribers will receive a 1% bonus in 2011 and 2012.
- Beginning in 2012, EPs who are not successful electronic prescribers may be subject to a payment adjustment or penalty.
- Medicare will determine successful electronic prescribers by analyzing claims data from January 1, 2011 – June 30, 2011.
- Providers will need to submit at least 10 electronic prescriptions during the first six months of 2011 to avoid a payment adjustment in 2012.
If this is your first year to participate in the e-Rx incentive program, make sure you submit at least 10 electronic prescriptions prior to June 30, 2011.
Timely Claims Submission
The Affordable Care Act reduced the maximum time period for submission of Medicare fee-for-service claims to one calendar year after the date of service. This change, which applies to services furnished after Jan. 1, 2010, reflects a reduction to the prior maximum timely filing deadline of 15 to 27 months.
The final rule revises the timely filing regulations to reflect these new requirements. The following filing deadlines now apply:
- Claims for services furnished before 2010 must be filed by December 31.
- Claims for services furnished on or after Jan. 1, 2010, must be filed no later than one calendar year after the date of service.
CPT CODE CHANGES
There are quite a few CPT code changes for 2011 as well as revised descriptions to several CPT codes and modifiers. The changes affecting ophthalmology for dates of service on or after January 1, 2011, are shown below.
- 65778 - Placement of amniotic membrane on the ocular surface for wound healing; self-retaining
- 65779 - Placement of amniotic membrane on the ocular surface for wound healing; single layer, sutured
- These two new CPT codes are to be used to report placement of preserved amniotic membrane over damaged ocular surface tissue either with or without sutures to facility ocular surface wound repair and healing.
- Code 65778 is self-retaining and does not require sutures.
- Code 65779 is to be used for a single layer that does require sutures.
- These codes cannot be reported in conjunction with scraping of cornea, code 65430, removal of corneal epithelium, code 65435, or ocular surface reconstruction using amniotic membrane, code 65780.
- Codes 65778 and 65779 should not be reported when the amniotic membrane is applied with tissue glue. Rather the unlisted code 66999 should be reported.
- 65780 - Ocular surface reconstruction; amniotic membrane transplantation, multiple layers
- Code 65780 was revised to specify involvement of multiple layers.
- For placement of amniotic membrane without reconstruction using self-retaining or single layer suture technique, use codes 65778 and 65779.
- 66174 - Transluminal dilation of aqueous outflow canal; without retention of device or stent
- 66175 - Transluminal dilation of aqueous outflow canal; with retention of device or stent
- Category III codes 0176T and 0177T have been converted to these two new permanent CPT codes due to an increase in the number of ophthalmologists performing this procedure and evidence to support the procedure’s efficacy and safety.
- These codes are used to report treatment of open-angle glaucoma involving accessing and dilating Schlemm’s canal to augment aqueous outflow facility.
- 66761 - Iridotomy/iridectomy by laser surgery (eg, for glaucoma) per session
- Code 66761was revised to state “per session” instead of “1or more sessions” to address the AMA RUC committee’s determination that this procedure be valued as a single surgical session with a 10-day global fee period. This code previously had a 90-day global fee.
- 67220 – Destruction of localized lesion of choroid (eg, choroidal neovascularization); photocoagulation (eg, laser), 1 or more sessions.
- This code has been revised to omit the parenthetical notes directing users to codes 0016T and 0017T which have been deleted in the 2011 CPT codebook.
- 92132 - Scanning computerized ophthalmic diagnostic imaging, anterior segment, with interpretation and report, unilateral or bilateral
- Category III code 0187T has been converted to code 92132 due to an increase in the use of this procedure and is intended for anterior segment SCODI.
- This code will be now paid bilaterally, not per eye. The national fee schedule amount (with no fee cut) for this new anterior segment scanning code will be about $35 which includes both eyes as opposed to approximately $90 for both eyes in 2010.
- 92133 - Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; optic nerve
- 92134 - Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; retina
- Code 92135 has been deleted and split into two new codes—92133 and 92134.
- Code 92133 describes SCODI of the posterior segment, optic nerve.
- Code 92134 describes SCODI of the posterior segment, retina.
- Codes 92133 and 92134 cannot be reported together.
- These codes will now be paid bilaterally, not per eye. The national fee schedule amount (without a fee cut) for these two new posterior segment scanning codes is $43 which includes both eyes as opposed to approximately $90 for both eyes in 2010.
- 92227 - Remote imaging for detection of retinal disease (eg, retinopathy in a patient with diabetes) with analysis and report under physician supervision, unilateral or bilateral
- 92228 - Remote imaging for monitoring and management of active retinal disease (eg, diabetic retinopathy) with physician review, interpretation and report, unilateral or bilateral
- These codes were developed to meet the needs of diabetic retinopathy screening programs which provide “remote imaging” and data submission to a centralized reading center.
- Code 92227 is intended for reporting “screening” examination for the asymptomatic patient at risk for a condition such as diabetes mellitus associated retinopathy.
- Code 92227 (the work of actually providing the remote imaging services) does not require a physician.
- Code 92228 is intended for reporting remote imaging used for monitoring management of patients with active retinal disease and requires a physician review, interpretation, and report. The patient is positioned before the retinal camera and images of each eye are obtained. The images are forwarded to a reading center where a physician reviews the images. An interpretation and report is prepared by the physician and a report sent to the referring provider.
- It is important to note that these remote imaging codes cannot be reported in conjunction with each other or with eye codes (92002-92014), posterior segment scanning, (92133 or 92134), fundus photography (92250), or E&M services (99201-99350).
- 0016T – Destruction of localized lesion of choroid (eg, choroidal neovascularization), transpupillary thermotherapy
- 0017T– Destruction of macular drusen, photocoagulation
- These two codes have been deleted from CPT.
- 0191T - Insertion of anterior segment aqueous drainage device, without extraocular reservoir; internal approach, into the trabecular meshwork
- This code has been revised to specify the trabecular mesh as the site in which the draining device is advanced and inserted.
- 0253T – Insertion of anterior segment aqueous drainage device, without extraocular reservoir; internal approach, into the suprachoroidal space
- This code is to be used for aqueous drainage devices inserted in the suprachoroidal space as the delivery site.
- 0192T – Insertion of anterior segment aqueous drainage device, without extraocular reservoir; external approach
- This code remains unchanged and describes an external approach to insert an aqueous drainage device such as the EXPRESS® Glaucoma Filtration Device.
2011 OIG WORK PLAN
The 2011 OIG Work Plan has several new areas of interest for ophthalmologists, optometrist and optical shops.
- Excessive Payments for Diagnostic Tests – The OIG intends to look at Medicare payments for high-cost diagnostic tests ordered by both the primary care physician and specialist for the same condition to determine if they were medically necessary. The high-cost tests were not identified, and this most likely does not affect ophthalmologists.
- Compliance with Assignment Rules – Under Medicare assignment rules, physicians and other providers agree to accept what Medicare pays and not bill patients more than the coinsurance and deductible for services provided. The OIG will review the extent to which providers comply with assignment rules and determine whether or not they are in violation of assignment agreement rules.
- Medicare Billings with Modifier –GY- The OIG will review the use of modifier –GY on claims submitted for services that are not covered by Medicare. Modifier –GY is only to be used with services that are statutorily excluded or do not meet the definition of a Medicare covered service. The OIG wants to make sure the services are truly non-covered and that patients are not unknowingly acquiring large medical bills for which they are responsible.
- Payment for Services Ordered or Referred by Excluded Providers – The OIG will review CMS’ oversight procedures for identifying and preventing payment for services ordered or referred by excluded physicians. No payment shall be made for any items or services furnished, ordered, or prescribed by an excluded individual or entity.
- Error-Prone Providers – The OIG will look at the top error-prone physicians who consistently submit claims found to be in error. They will conduct additional medical reviews on the top error-prone providers and request refunds of any overpayments made by Medicare.
ICD-10
Effective October 1, 2013, ICD-9-CM diagnosis coding will be replaced with ICD-10. The ICD-10 coding nomenclature will contain 7 digits (alpha and numeric). The current ICD-9 version only contains 5 digits. This requires computers to be upgraded from Version 4010 to Version 5010 programming. You need to make sure your computer vendor and clearinghouse has met the Version 5010 requirements.
ICD-10 will require extensive training of all persons who write in the medical record or bill insurance. This includes physician training. Some sources suggest that training start one year prior to the “go-live” date of ICD-10 implementation. You will also need to budget for computer system updates, encounter form changes, and staff training.
It is not too soon to start learning about the ICD-10 implementation.
CMS CLARIFIES H&P AND REASSESSMENT IN ASC
CMS recently released a Memorandum clarifying Ambulatory Surgical Center (ASC) Interpretive Guidelines for a comprehensive History & Physical (H&P) assessment. The issue has been of concern to the ASC community since the implementation of the new Conditions for Coverage (CfCs) took effect in May, 2009.
The new guidelines states:
- A comprehensive H&P and surgery may be performed on the same day as long as the H&P is performed by qualified personnel, is comprehensive, and is placed in the patient’s ASC medical record prior to surgery.
- If the H&P is conducted in the ASC on the same day as the surgical procedure, then some elements of the required surgical reassessment may be incorporated into the H&P. This does not apply to the anesthetic/procedure risk assessment, which must be performed by an anesthetist prior to surgery and after the H&P.
The H&P still cannot be performed more than 30 days prior to the surgery, and it is not acceptable to conduct the H&P after the patient has been prepped and brought into the operating room or procedure room since the purpose of the H&P is to determine whether there is anything in the patient’s overall condition that might preclude the surgery.
2010 MEDICARE UPDATE
Uncertainty with the 2010 physician fee schedule and the looming 21.2% fee cuts, consultations no longer being paid by Medicare, and new Ambulatory Surgery Center (ASC) Conditions for Coverage guidelines are a few of the issues facing ophthalmology in 2010. Below is a recap of the Medicare changes for 2010.
Physician Fee Schedule
The 2010 final rule contained a 21.2% fee cut for physician fees. Congress approved two extensions to the fee cuts freezing the rates at the modified 2009 physician fee schedule rates through March 31, 2010. Congress failed to approve another extension before Spring recess and the Centers for Medicare and Medicaid Services (CMS) held claims through April 14, 2010, to give Congress additional time to act.
On April 15, 2010, President Obama signed into law the “Continuing Extension Act of 2010” which extends the zero percent update through May 31, 2010. The law is retroactive to April 1, 2010. The April 1 claims that were being held by CMS were released for payment on April 15, 2010. Due to the new law, CMS will make retroactive adjustments to any claims that have been paid the 21.2% reduction.
The new Extension Action will, hopefully, give Congress, CMS and the medical societies time to work on a more permanent fix to the flawed Sustainable Growth Rate and the physician fee schedule payments.
Consultations
Effective January 1, 2010, Medicare no longer pays for consultations. This includes consultations performed in the office or outpatient department of the hospital, inpatient hospital consultations, and consultations performed in a nursing home.
Consultations performed in the hospital or nursing facility should now be billed with the initial hospital care or initial nursing facility care codes. Admitting physicians will need to append the AI modifier to let Medicare know they are the “principal physician of record” and responsible for the patient’s total care while in the hospital or nursing home. Subsequent care visits will need to be reported as subsequent hospital care codes and subsequent nursing facility care codes. While Medicare requirements have reserved the use of initial hospital or nursing home visits for the admitting physician in the past, CMS has made the above change effective January 1, 2010.
Consultations requested by a referring physician in the office or outpatient department of the hospital will need to be billed as new or established patient visits, either evaluation & management services or eye codes. CMS redistributed the savings by increasing the work RVUs for new or established office visits and initial hospital and nursing home visits. They also increased payment for the global surgery to reflect the higher value of office visits furnished during the global fee period. The eye codes, 92002-92014, were not included in the RVU increase.
Incentive Bonuses
CMS will continue its 2% incentive bonus payments for physicians who participate in the Physician Quality Reporting Initiative (PQRI) program using claims-based or registry-based reporting and the Electronic Prescribing (E-Prescribing) program.
- PQRI now has two reporting periods – January 1, 2010, through December 31, 2010, or July 1, 2010 through December 31, 2010. If you have not yet begun to report PQRI for this year, you can still receive the 2% bonus on the 6 month reporting period. PQRI can be reported via claims based reporting or a Registry. Remember the 2% bonus is based on the total allowed covered services paid by Medicare during the reporting period.
- E-Prescribing is much easier to report in 2010. You only have to report on one measure indicating a patient visit results in an E-Rx being placed, and you only have to report 25 times during the reporting period of January 1, 2010 through December 31, 2010. E-Prescribing can be reported through qualified registries or through qualified EHR products and is now permitted at the group level rather than at the individual eligible practice level.
ASC Fee Schedule
ASCs received a 1.2% inflation increase in the conversion factor for 2010 as well as a 50-cent increase in the ASC conversion factor. In addition, the Hospital Outpatient Department (HOPD) received a 2.1% increase which directly impacts the 2010 payments for ASCs.
ASCs are in their third year of a four-year payment transition which is a 75/25 blend of the 2007 ASC payment rates and the current HOPD rates. The full 65% transition rate will be implemented in 2011.
ASC Conditions for Coverage
In May, 2009, new ASC Conditions for Coverage (CfCs) were to be implemented by ambulatory surgery centers and outpatient department of the hospital to improve infection control and provide 24 hour advance notices to Medicare beneficiaries.
The state survey agencies have begun unannounced on-site inspections. They come with 3-5 inspectors and they are there 3-5 days. If you have not yet implemented these new guidelines, you should do so immediately. Go to the CMS website at: http://www.cms.gov/CFCsAndCoPs/16_ASC.asp. Or contact Rose and Associates for additional information.
Diagnosis Codes
There are a few new diagnosis codes for ophthalmology in 2010.
- 209.31 – Merkel cell carcinoma of the face (eyelid, including canthus)
- 209.31 – Merkel cell carcinoma of the face (eyelid, including canthus)
- 239.8 – Neoplasms of other specified sites (Retina and choroid, dark area of retina, retinal freckle)
- 239.89 – Other specified sites
- 372.06 – Acute chemical conjunctivitis (Acute toxic conjunctivitis).
- Excludes burn of eye and adnexa (940.0-940.9), chemical corrosion injury of eye (940.2-940.3)
- V10.90 – Personal history of unspecified malignant neoplasm
- Personal history of malignant neoplasm NOS
- V87.44 – Personal history of inhaled steroid therapy
- V87.45 – Personal history of systemic steroid therapy
- Personal history of steroid therapy NO
Practices are urged to purchase new ICD-9-CM diagnosis coding manuals annually to avoid possible payment delays or denials. Don’t forget also, that ICD-10-CM is coming October 1, 2013. It is not too soon to learn about this new coding system and start working with your vendors to make implementation easier.
2010 OIG WORK PLAN
Each year, the Office of Inspector General (OIG) releases a Work Plan outlining areas of interest with regard to program enforcement for CMS. There are four new areas of concern for 2010 and three repeat areas of concern.
- E-Prescribing Incentive Payments. The OIG will assess if, and if so, to what extent incentive payments for e-prescribing activities in 2009 were made in error. If erroneous payments were made, the OIG will assess CMS’s actions to remedy erroneous payments and its plans for overseeing payments made. Ophthalmology is one of the top participating specialties of the e-prescribing program.
- Compliance with Assignment Rules. Physicians participating in Medicare agree to accept the Medicare allowed amount by the carrier as the full charge for the items or services provided less any coinsurance and deductible amounts. The OIG will mainly assess beneficiaries’ awareness of their rights and responsibilities regarding potential billing violations and Medicare coverage guidelines. To avoid exposure in the future, make sure staff is aware of the basic billing rules for participating providers. If an over-collection is made in error, refund the patient immediately rather than holding the overpayment towards a future visit.
- Comprehensive Error Rate Testing (CERT) Program. The OIG will review the CERT payment methodology for determining the 2009 error rates. Historically, the primary focus has been on misuse of modifiers, high levels of exams (level 4 E&M and code 92004), and other outliers identified in their paid claims review. CMS has contracted with a review organization to perform a random review of its CERT contractor’s payment determinations for 1,000 Part A and Part B claims. They will determine whether the independent review organization met its contractual obligations to CMS and will provide an analysis of the organization’s review. Based on the outcome of the review, we could see CERT audits increase in the future.
- Services Billed with Dates of Service After Beneficiary’s Date of Death.The OIG will review claims with dates of service after beneficiaries’ dates of death to identify and recover improper payments. This issue has been a work in progress and will most likely continue for a few more years. This should not be an issue in ophthalmology, but the billing department needs to make sure any claims submitted to Medicare after a patient’s date of death is filed with the date the service was actually performed, not the posting date.
- Place of Service Errors.The OIG will again review physician coding of place of service on Medicare Part B claims for services performed in ambulatory surgery centers and outpatient hospital departments. Federal regulations provide for different levels of payments to physicians depending on where the services are performed. Medicare pays a higher amount when a service is performed in a non-facility setting, such as a physician’s office, than it does in an ASC or hospital outpatient department.
Since this is an ongoing area of concern, you need to make sure all your services are billed with the correct place of service. If a service, such as a laser, is performed on the ASC side of the firewall, you must indicate place of service as ASC on the claim form. It does not matter that you consider the laser room an extension of the office. If the service is performed behind the ASC firewall, it is considered place of service ASC.
- E&M Services Provided During Global Fee Period. The OIG is continuing to review industry practices related to the number of office visits provided by physicians and reimbursed as part of the global surgery fee. This is an ongoing investigation with periodic recommendations made to CMS.
While it was not specifically addressed in the 2010 OIG Work Plan this year, the use of modifier -24 during the global fee period is an ongoing issue. Before appending the -24 modifier, ask yourself if the patient would have had the problem if surgery had not been performed. If the answer is no, do not append modifier -24 to the office visit. A different diagnosis does not automatically justify billing the office visit if the problem is directly related to the surgery.
- Use of the –GY Modifier. Modifier –GY is to be used for coding services that are statutorily excluded or do not meet the definition of a covered service. Medicare patients are liable, either personally or through other insurance, for all charges associated with these services. Providers are not required to provide patients with advance notice of charges for services that are excluded from Medicare by statute. As a result, patients may unknowingly acquire large medical bills that they are responsible for paying. The OIG plans to examine patterns and trends for physicians’ and suppliers’ use of modifier –GY.
MANDATORY PECOS ENROLLMENT
In October of last year, CMS implemented the first phase of a new policy requiring physicians who order or refer services to be enrolled in the Provider Enrollment, Chain and Ownership System (PECOS) database. Physicians were supposed to be enrolled in the database by January 4, 2010, or claims would be rejected.
Currently billing physicians receive a warning edit that makes it appear a claim has been denied. The billing physician, of course, has no control over whether the referring physician is enrolled in PECOS. The second phase of the policy requires physicians who enrolled in Medicare prior to 2003 to re-enroll through PECOS.
CMS has delayed implementation of the second phase of modifications to PECOS regarding ordering/referring providers from April 5, 2010, until Jan. 3, 2011.
Prior to the Jan. 3, 2011, implementation date CMS will:
- Continue to place warnings on claims in which the ordering/referring physician is not enrolled in PECOS;
- Update the Medicare Ordering/Referring file;
- Remind providers who enrolled in Medicare prior to 2003, but have not completed the revalidation process, to submit a new enrollment application either in the paper form or by using Internet-based PECOS.
You can go to the CMS website at www.cms.hhs.gov/MedicareProviderSupEnroll to see if you are currently enrolled in PECOS. Just click on “Ordering/Referring Report” on the left-hand side and download the list. If you are not on the list, you need to work towards re-enrolling via PECOS prior to January 3, 2011.
PREMIUM IOLS
Physicians may 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
- Coding & Reimbursement Seminar for Alcon Products. Speaker: E. Ann Rose.
- Atlanta, GA – April 29, 2011
- Baton Rouge, LA – May 19, 2011
- New York, NY – June 9, 2011
- Raleigh, NC – July 14, 2011
- Minneapolis, MN – August 11
- Los Angeles, CA – September 15, 2011
- Albuquerque, NM – October 6, 2011
To register for Alcon seminars go to the ARS website at: http://www.alcon.com/en/professionals/reimbursement-services.asp
- National Medical Association Annual Meeting, Washington, DC – July 27, 2011. Speaker: E. Ann Rose. http://www.nmanet.org/index.php/ConvJspargo/convention_overview
- Alcon/ASOA Ophthalmic Symposium, August 27, 2011, San Antonio, Texas. Speaker: E. Ann Rose.
www.asoa.org
- Caribbean Eye ACES/SEE Meeting, Grand Cayman, Cayman Islands - February 3-7, 2012.
Speaker: E. Ann Rose. http://caribbeaneyemeeting.com/contact.php
- ASCRS Winter Update, Playa del Carmen, Mexico - February 16-20, 2012. Speaker: E. Ann Rose. www.winterupdate.net
- ASOA Congress & Symposium, Chicago, IL, April 20-24, 2012. Speaker: E. Ann Rose.
www.asoa.org
Please contact us or call (800) 720-9667 for additional information regarding the above lectures and meetings.