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AOA’s committee participation key to optometry’s fair treatment under Medicare

November 24, 2012

Thanks to the AOA’s leading role in helping shape Medicare’s payment and coding policy, optometry recently celebrated 26 years of fruitful participation in the Medicare program.

Physician services have been reimbursed according to a standardized physician payment schedule based on a resource-based relative value scale (RBRVS) for the past two decades. In the RBRVS system, payments for services are determined by the resource costs needed to provide them. The cost of providing each service is divided into three components: physician work, practice expense and professional liability insurance. This figure is further adjusted for geographical differences in costs and, finally, by an arbitrary conversion (a monetary amount determined by the Centers for Medicare & Medicaid Services (CMS).

Annual updates to the physician work relative values are based on recommendations from a committee involving the American Medical Association (AMA) and delegates from the 31 national medical specialty societies.

The AMA/Specialty Society RVS Update Committee (RUC) was formed in 1991 to make recommendations to the CMS on the relative values to be assigned to new or revised Current Procedural Terminology (CPT) codes. The RUC is responsive to changes in the health care delivery model that emphasizes primary care delivery.

The 31 members of the RUC represent the entire medical community. The AOA has held a seat at the Health Care Professionals Advisory Committee (HCPAC) since 1991. The HCPAC represents physician assistants, social workers, physical therapists, occupational therapists, podiatrists, psychologists, audiologists, speech pathologists, registered dieticians and optometrists. The HCPAC was formed to allow for participation of limited license practitioners and allied health professionals in the RUC process. Optometry is unique in that all of our codes are developed in conjunction with the American Academy of Ophthalmology (AAO) and are presented to the full RUC rather than to the HCPAC.

The workload of the RUC is determined by several interested parties, including the CPT Editorial Panel that may introduce new or revised CPT codes for valuation and the CMS whose surveillance of billed codes may detect certain trends (i.e., abrupt increase in volume or anomalous billing combinations) and seek explanations from the interested specialty societies.

The specialty society may then seek either to explain the frequency and present use of the code or to develop a survey of its member providers in order to ascertain an accurate current value for the service in question.

The specialty societies conduct the surveys, review the results, and prepare their recommendations to the RUC. Because optometry uses the same codes as the AAO, it coordinates its survey procedures and develops a consensus recommendation with them. The written recommendations are then sent to the RUC. These recommendations consist of physician work, time, and practice expense.

The specialty advisers for ophthalmology and optometry present the recommendations at the RUC meeting. The presentations are followed by a thorough question–and-answer period during which the advisers must defend every aspect of their proposal. The RUC may decide to adopt a specialty society’s recommendation, refer it back to the specialty society, or modify it before submitting it to the CMS.

CMS Medical Officers and Contractor Medical Directors review the RUC’s recommendations. The culmination of all of this work is the Medicare Physician Payment Schedule, which includes the CMS’s review of the RUC recommendations and is published in late fall.

In July, the CMS released its proposed changes to the Medicare Physician Fee Schedule for 2013. As expected, the rule includes a 27 percent reduction in payments due to continuation of the flawed sustainable growth rate (SGR) formula.

The CMS proposed additional cuts in its multiple procedure payment reduction (MPPR) policy for 2013. The CMS proposed to apply the MPPR to the professional component (PC) of certain diagnostic imaging services when two or more physicians in the same group practice furnish services “to the same patient, in the same session, on the same day.”

The CMS proposed to apply a 25 percent MPPR to the technical component (TC) of certain diagnostic ophthalmological services. The CMS argued that the listed services represent codes frequently billed together and that various clinical labor activities would not be duplicated for subsequent procedures.

The CMS proposed to apply the 25 percent MPPR to TC-only services and to the TC portion of global services when two or more of the designated services (that is, two or more of the ophthalmology services) are furnished by the same physician (or physicians in the same group practice) to the same patient on the same day.

The CMS reviewed all of the diagnostic services, including Fluoroscein Angiography (92235) and Fundus Photo (92250), when determining that the technical component of some services should be cut 25 percent for the second procedure. In addition to 92235 and 92250, the CMS included eye ultrasound codes and other services including all visual field and optical coherence tomography (OCT) tests.

The AOA will be making comments regarding the MPPR.

While the CMS has examined the billing tendencies of all the medical specialties, optometry is one of the few professions that have remained on the plus side in the estimated impact on total allowed charges by specialty through the years.

The cuts in diagnostic testing have been offset by the relative increases in the evaluation and management (E/M) services and the general ophthalmological codes.

The AOA will update members once the final physician payment fee schedule is published later in November.

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