Medicare announces policy changes for 2013

By Roger Jordan, O.D., AOA Federal Relations Committee chair

With every new year comes new Medicare policies. In 2013, as in most years, many new or revised Medicare policies will directly impact optometrists and the patients they serve with effects on payments for services and incentive programs.

As of press time, Congress had yet to address the greatest Medicare issue facing optometry—a planned, statutorily required 26.5 percent cut in Medicare payments to physicians, the Centers for Medicare & Medicaid Services (CMS) announced a number of other policy changes that will affect reimbursement in optometric practice. Practicing optometrists should be aware of them.

First, the good news: As the result of continued adoption of survey data, Medicare is placing greater value on medical eye care procedures under its Medicare Resource-Based Relative Value Scale (RBRVS). The scale assigns values to all Medicare-reimbursable procedures that are then multiplied by the Medicare Conversion Factor (set at $34.0367 in 2012) to establish the dollar reimbursement for each procedure. The increase in relative value units (RVUs) assigned to many eye care procedures over recent years effectively means that whatever might be done to increase or decrease Medicare reimbursement overall, fees for medical eye care services would be higher than they would have been otherwise.

In fact, for 2013, if Congress opts to hold payment rates steady, the CMS expects optometrists will be paid 1 percent more than last year. There would also be a slight increase of 0.8 percent for covered post-cataract eyeglasses provided to Medicare beneficiaries. This would make 2013 the second year of positive updates for prosthetics provided by ODs under Medicare.

The primary reason most medical eye care services have been valued higher by Medicare for four consecutive years is the implementation of new underlying data assumptions based on the Physician Practice Information Survey conducted by the American Medical Association (AMA) with AOA support.

The AOA continues to be an active participant in the AMA Relative Value Update Committee (RUC) to fight for fair valuation of services provided by optometrists (see November AOA News).

Some reductions

While the relative value of most services provided by optometrists will increase slightly, some services in some situations will be reduced significantly.

Health policy experts and economists pressured Congress and the CMS to lower payments in certain clinical situations.

For example, multiple procedure payment reductions for certain ophthalmic imaging services will result in lower payments when more than one service is provided to the same patient in the same day (see December AOA News). For details on this new payment reduction policy, see http://tinyurl.com/cms75g3.

Health policy experts and economists also pressured Congress and the CMS to review payments for more than 1,000 specific services, based on a variety of theories that suggest the reimbursements for those services might be too high.

Frequently billed procedures are often targeted for review. Because cataract is a very common clinical condition and cataract surgery is frequently performed, the CMS has required the AMA to review the valuation of the code.

The AOA has worked with colleagues in ophthalmology to fight for fair payment for the code, but the AMA recommended a reduction in the value assigned to the work that goes into the service.

The CMS then made revisions, which will result in an 8 percent to 13 percent reduction in payment for codes 66982 and 66984.

Two other services reviewed were specular microscopy/endothelial cell count (code 92286) and visual fields (code 92083). Surveys of physicians confirmed the work involved with visual fields, but not the work for microscopy/cell count, so code 92286 has also been cut. The impact of these reductions will be mitigated if Congress prevents the 26.5 percent cut in the conversion factor.

Incentive programs and value-based payment

In the face of such reductions, participation in Medicare incentive programs is becoming increasingly important as a means of supplementing reimbursements. Optometrists can take steps to increase their Medicare payments in 2013 by participating in the Physician Quality Reporting System (PQRS), electronic prescribing (e-Rx), and implementing electronic health records (EHR). (Practitioners can earn PQRS and e-Rx bonus payments, or PQRS and EHR incentive payments, but cannot receive both the EHR and e-Rx bonus in the same year.)

The bonus for electronic prescribing in 2013 is 0.5 percent, and optometrists remain exempt from the Medicare penalty for not prescribing electronically. The PQRS bonus is 0.5 percent for 2013, and, importantly, attempting to earn the PQRS bonus will also serve for optometrists to avoid a payment penalty applied to Medicare claims in 2015.

Congress extended the PQRS bonuses through 2014, but has also authorized penalties that begin in 2015. For more information on how to successfully participate in the PQRS program, see www.aoa.org/pqrs and future issues of AOA News.

The Stage 1 meaningful use requirements remain in effect for the EHR incentive program in 2013, but Stage 2 requirements will take effect in 2014 requiring additional software upgrades by the end of this year.

Congress has also enacted a value-based payment modifier (VM) for 2015 that the CMS will implement using performance in 2013 for large groups of 100 or more physicians, and will apply to all physicians by 2017. The simplest way for a large group to avoid a negative payment modification in 2015 is to successfully participate in PQRS in 2013. The AOA News will provide more information about the VM over the next several months.

Other policy changes

In a welcome move, the CMS effectively removed eyewear from a new policy that on July 1, 2013, will require Medicare beneficiaries be seen face-to-face by a physician prior to receiving durable medical equipment. The policy will not apply to prosthetics such as post-cataract eyeglasses.

The CMS has also instituted a change, effective this year, that recognizes optometrists can order portable X-rays under Medicare, subject to their state scope of practice. Prior to 2013, portable X-rays could only be ordered by MD and DOs. While optometrists are not likely to order portable X-rays, the AOA supported the change, with a provision to make coverage dependent on state scope of practice.

The Medicare enrollment fee will increase to $532. Optometrists remain exempt from the fee when enrolling as physicians, but not when enrolling as suppliers of durable medical equipment, prosthetics, orthotics, and suppliers (DMEPOS).

For additional information, see the December AOA News or http://tinyurl.com/a6cpp69.

For 2013, the Part B standard monthly premium rate for Medicare beneficiaries has increased to $104.90 and the Part B annual deductible increased to $147.00.

The revised annual limit on occupational therapy services will be $1,900. However, the CMS is implementing many other changes for patients who receive therapy services. The CMS will begin collecting claims-based data, using codes to indicate functional limitations at various points of care. The collection will be tested in the first six months of the year and required for payment as of July 1.

Look for additional information in AOA News in the months ahead.