The Centers for Medicare and Medicaid Services (CMS) has implemented significant changes to retinal imaging codes despite strong opposition from the American Optometric Association (AOA) and others. Three new codes have now replaced 92135 – “scanning computerized ophthalmic diagnostic imaging, posterior segment, (e.g., scanning laser) with interpretation and report, unilateral.” For a full report on these important coding changes, please click here.
The AOA is angry about what happened to the scanning laser codes. AOA vigorously fights any inappropriate reduction in the value of codes that describe services frequently performed by optometrists. For more than a year, the Association has worked with colleagues in ophthalmology specifically to prevent any unnecessary reduction in the reimbursement for ophthalmic diagnostic imaging. Unfortunately, the change in codes from 92135 to 92133-34 also resulted in a change in coding policy that has substantially reduced the amount doctors will receive for using this tool as part of their patient care.
The changes to these codes occurred despite AOA’s actions. The American Medical Association’s Current Procedural Terminology (CPT) Editorial Panel establishes CPT codes and descriptors. AOA represents optometry at the CPT meetings. Together with ophthalmology representatives, AOA argued against the devaluation of these codes.
The CPT created 92135 as a unilateral code in 1998 and even then there was some controversy about whether the code should be bilateral. Since then, Congress and the Centers for Medicare & Medicaid Services (CMS) have sought ways to reduce payments for imaging done more than once on the same patient on the same day. Local carriers also commonly limited the number of times this service was covered for a patient in a year.
The use of scanning computerized ophthalmic diagnostic imaging grew quickly, particularly for ophthalmology. By 2009, code 92135 was billed 6.3 million times (86.45 percent) by ophthalmologists and 0.9 million times (12.78 percent) by optometrists. Overall growth topped 135 percent in the last five years and nearly 5000 percent over the last decade.
The significant increase in use of these codes, as a result of new technology and changing practice patterns (particularly by retinal surgeons), put an undue spotlight on these services. In 2008, CMS highlighted 92135 as one of 110 codes with a high rate of growth (more than 10% in three consecutive years). CPT code 92135 was actually the No.50 code on the list in overall growth from 2004 to 2007 (104%). Of those 50 fastest growing codes, only one code accounted for more Medicare dollars paid than CPT code 92135.
More recently, AMA analysis of thousands of CPT codes showed that 92014, 92135, 67028 (intravitreal injection of a pharmaceutical agent), and 66984 (extracapsular cataract removal with insertion of intraocular lens prosthesis) are among the 40 codes with the largest increase in allowed charges (total dollars) from 2008 to 2009. And among those 40, 67028 and 92135 ranked sixth and seventh in greatest change in frequency per beneficiary (28 percent and 21 percent, respectively). For 2011, CMS also found an excuse to cut 67028, much to the frustration of ophthalmology which most frequently bills that code. The high rate of growth, regardless of medical necessity and appropriateness, stacked the deck against code 92135.
Codes whose use and cost increase quickly are typically viewed by CMS, the Government Accountability Office (GAO), and the influential Medicare Payment Advisory Commission (MedPAC), and others as overpaid. CMS was determined to find a way to reduce the payment for these services. Imaging is the fastest growing category in the physician fee schedule, increasing 37 percent since 2003. There is a belief at the highest level of health policy expertise that codes experiencing a significant growth in utilization should be devalued. The data show the numbers but never explain what’s happening clinically or in practice, so the default position is that there is no legitimate reason for increased use and cost.
Organized medicine would not accept new codes as unilateral despite the arguments made by optometry and ophthalmology experts. When the AMA created the new CPT codes, Medicare and third party payers had to implement them. The Health Insurance Portability and Accountability Act (HIPAA) of 1996 requires all payers, public and private, to follow a standard code set, which CMS determined would be the CPT codes. Once the CPT codes were changed, all payers had to abide by them as of January 1.
Another AMA-organized entity, the AMA/Specialty Society Relative Value Update Committee (RUC), recommends “relative values” to CMS for Medicare payment. Medicare pays for a service based on its relative value and the single conversion factor for the physician fee schedule, with additional adjustments based primarily on the geographic location of the service. These values are not based on clinical judgments about the beneficial value of the service but on data about the actual resources used to provide the service. AMA distributes survey instruments to the specialty societies. If a code to be surveyed is used by optometrists, the AOA will send out surveys to random practicing optometrists for recommendations of the physician work associated with the surveyed code(s). Physicians receiving the surveys are asked to evaluate the work involved in the new or revised code relative to pre-selected reference codes. Thus, AOA urges members to participate when they receive survey requests.
AOA and ophthalmology exert considerable energy participating in the RUC. AOA shares a vote with other non-MD physicians and ophthalmology is also represented. When an ophthalmologic service is reviewed, both optometrists and ophthalmologists participate in the survey process. The better the response from practicing physicians, the stronger the arguments by AOA and ophthalmology at the RUC about proper valuation of a code. The RUC debate over the value of codes is intense because every incremental increase in the relative value of a code results in a corresponding incremental reduction of relative value in every other code in the physician fee schedule because of CMS rules on budget neutrality.
When the dust settled last year, the two new codes were valued for 42.9 percent more work than 92135 in part because the new codes assumed scanning both eyes in a single service rather than treating each eye scan as a separate service. However, as practice expenses and other components of the relative values were factored in, the relative values for the new codes were only 7.4 percent higher than 92135. Although Congress mandated a 0.0 percent update in the physician fee schedule (see article), other changes in Medicare policies and the budget neutrality requirement caused CMS to reduce the conversion factor by 7.9 percent. As a result, the payment for 92133 or 92134 ($44.51 before local adjustments) is slightly less in 2011 than the payment for 92135 was ($44.98) in the latter half of 2010 but slightly higher than the payment ($44.02) in the first half of 2010. In practice, the potential reimbursement for the scanning laser service is cut in half because doctors can only bill the new codes once (instead of twice) when both eyes are scanned.
This outcome has been troubling for AOA, optometrists, and ophthalmologists. However, there is a silver lining in Medicare reimbursement for 2011.
CMS has predicted that the utilization of 92135 will transfer to the new codes 92133-34. However, thanks to the coding policy, CMS expects use of the new codes to be about 60 percent less than the use of the old code. CMS factored this significant reduction into its estimate for the impact of the physician fee schedule on optometry.
According to the CMS calculation, the increases in nearly all other codes typically billed by optometrists will more than offset the loss of income from the scanning laser codes. While the actual impact for a doctor depends on the mix of services they provide to Medicare beneficiaries, overall optometry will be paid more in 2011 than ever before by Medicare. Of the top 70 codes most commonly used by ODs, 80 percent will be paid more in 2011 than 2010. In the ongoing tug of war among all physician specialties with each other and with Medicare, optometry is a big winner in recent years.
The AOA understands that the high cost of the scanning laser, coupled with the reduction in reimbursement for using that technology to improve patient care, and has troubled many optometrists. The AOA will continue to fight for appropriate reimbursement for all services provided by ODs. The AOA hopes that the increased reimbursement for many other codes will provide a positive impact for optometrists in 2011 and will reinstate some confidence for optometrists who use the scanning laser machines in their practices.
AOA has heard from many members that the new codes 92133 and 92134 are being denied by their local payer. There have been widespread claims processing problems in Medicare and these denials are probably an indication that the payer has not successfully updated its software with all of the 2011 changes. Please let your state association know which payer — Medicare, Medicaid, Medicare Advantage, Medicaid managed care, or third party payer. It may take another week or two for all payers to be properly processing claims.
AOA members with questions or concerns should contact the AOA Washington Office directly at 1-800-365-2219 or ImpactWashingtonDC@aoa.org
