News from the AOA's Blog

Edited by Chuck Brownlow, O.D., AOA CodingToday and Medical Records consultant

Three new codes will replace 92135. 2011 Current Procedural Terminology (CPT©, American Medical Association) includes one very significant change affecting eye care. 92135. “Scanning computerized ophthalmic diagnostic imaging, posterior segment, (e.g., scanning laser) with interpretation and report, unilateral,” has been eliminated.

In turn, CPT created three new codes for imaging, one for reporting anterior segment imaging and two for posterior segment imaging. The following codes and definitions will be in effect Jan. 1, 2011:

• 92132 — Scanning computerized ophthalmic diagnostic imaging, anterior segment, with interpretation and report, unilateral or bilateral (replaces the 2010 CPT Category III code, 0187T)
• 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

Caveats to consider regarding the new codes: 

• 92135 was considered ‘unilateral’; billed once per eye
• Each of the new imaging codes is considered bilateral; billed once, whether one eye or both eyes are scanned
• 92132 may be billed on the same day as either 92133 or 92134, assuming the diagnoses involved with the visit support doing both procedures
• 92133 and 92134 are mutually exclusive and cannot be billed on the same day, regardless of diagnosis

Although many doctors will appreciate that the CPT Editorial Board has replaced the Category III code with a Category I code, they are likely to be disappointed to learn that CPT changed all three imaging codes to “bilateral.”

The disappointment may be deepened, as Medicare’s relative value for 92132 is below the relative value for the 92135, and the values for 92133 and 92134 are only very slightly higher (+0.01) than the value for 92135.

The chart shows the relative values that Medicare has created for each of the new codes (column 2), as well as the projected Medicare Allowed Amounts if Medicare’s projected fee schedule goes into effect on Jan. 1 (column 3).

Column 4 shows the values for these services if Congress acts prior to Jan. 1, 2011, to retain the current conversion factor. 

In any case, the 2011 Medicare reimbursements for performing imaging on both eyes are likely to be considerably lower than those for 92135 in 2010.

Medicare fees still in doubt

The “lame-duck” Congress acted to prevent the enormous reductions in Medicare reimbursements that were facing Medicare providers. for 2011, but a long-term plan has yet to be acted upon.

If Congress had failed to act prior to Dec. 31, across-the-board decreases would be seen in Medicare-allowed payments of nearly 30 percent.

To put this in perspective, Medicare adopted the Resource Based Relative Value System in 1992. Since then, the Medicare payments have been based on the simple formula, Fee = Relative Value x Conversion Factor. 

The original Conversion Factor was $30.11 in 1992, 18 years ago. If the Medicare 2011 Conversion Factor was allowed to go into effect on Jan. 1, Medicare’s allowed amounts would be well below 2010 and even 15.2 percent below what they were in 1992! 

The formula that the Centers for Medicare & Medicaid Services (CMS) uses to calculate the allowed amounts each year is badly flawed, and everyone, including CMS representatives, agrees that it must be fixed. 

In spite of that agreement, the formula continues to be the only one available for the CMS to use, necessitating congressional action every year to fully or partially adjust the numbers to provide fairer reimbursement for providers of Medicare services. 

For ODs who have never contacted their U.S. members of Congress on any issue before, this issue must motivate them to contact them now.

The AMA, AOA and all other health professional associations are working vigorously to avert the reductions and to urge correction of the formula, but it is constituent contacts that are needed now. “Constituent” means “you”!

Concerned doctors can learn more about this important issue and even take action by using the AOA’s Online Legislative Action Center at: www.aoa.org/x4821.xml or by contacting the AOA Washington office directly at ImpactWashingtonDC@aoa.org.