From the American Academy of Ophthalmology

The Centers for Medicare and Medicaid Services today issued the 2013 Medicare physician fee schedule, which indicates a 3 percent payment cut for ophthalmology. The reduction is due largely to CMS’ implementation of cuts in reimbursement for eye codes when two or more diagnostic services are billed by the same physician on the same day for a patient. Changes in work values for cataract and complex cataract surgery also contribute to the reduction. Ophthalmologists face an additional 27 percent cut on Jan. 1 unless Congress acts to derail the sustainable growth rate formula currently used to calculate Medicare physician pay. The final rule includes a conversion factor of 25.08, which reflects the SGR cut. Following are key takeaways from the Academy’s initial review of the rule.  ­

Payments for concurrent tests to be reduced 20 percent
CMS is moving forward with implementation of cuts in reimbursement for eye codes when more than one diagnostic service is billed by the same physician in the same day for a patient. The second and subsequent procedures will be cut 20 percent, despite lobbying efforts by members of Congress, the Academy and other ophthalmic associations to stop the cut. The Academy argues that the cut is unfounded as there is no duplication of work and resources. CMS stands by its assertion, however, that there are additional cost efficiencies when such testing is performed at the same visit. As a result, Medicare payments to ophthalmology could be cut more than $1 million annually.

Cut to key ophthalmology services offset by increase in practice expense values
CMS will implement lower cataract surgery work values recommended by the American Medical Association/Specialty Society Relative Value Scale Update Committee in 2013. Those cuts will be partially offset, however, by an increase in practice expense values. The cut affects CPT code: 66984 Extracapsular cataract removal with insertion of intraocular lens prosthesis, CPT code 66982: Complex cataract removal and CPT code 92235: Fluorescein angiography.

Academy mobilizing members to stop SGR cut
The Academy is mobilizing members to urge lawmakers to derail the SGR cut when they return to Washington mid-month. Member activism is a key component of the Academy’s plan to drive legislative action on this immediate threat. The Academy provides online tools for members to contact their representative and senators to encourage swift action. In addition, members will have an opportunity to sign the “Declaration of Independence from the SGR Formula” petition at the 2012 Joint Meeting of the American Academy of Ophthalmology and the Asia-Pacific Academy of Ophthalmology. Members will be able to sign the petition at the OPHTHPAC® fund booth in the McCormick Center’s Grand Concourse Lobby, near Starbucks. The petition will be presented to lawmakers when they return to Washington following the elections.

CMS provides more ways to avoid PQRS penalty
As a result of Academy efforts, CMS is reducing reporting requirements for PQRS in 2013, making it easier for physicians to avoid a 1.5 percent cut to their Medicare payments in 2015. CMS will only require that physicians attempt to report on one PQRS measure in 2013, instead of three. Ophthalmologists who make a good-faith effort will avoid the 2015 penalty. Physicians also are able to earn a PQRS incentive payment in 2013 by successfully reporting on three measures, or one measure group.

Improvements made to cataract measure group reporting
In 2013, CMS will reduce the number of Medicare patients a physician must report on to qualify for a 0.5 percent PQRS incentive using the cataract measure group option. Ophthalmologists will only have to report on 20 patients, down from 30. A majority of those patients must be enrolled in the Medicare fee-for-service program. Measure groups offer an advantage over reporting individual PQRS measures because it is not necessary to report on every patient that qualifies for the measure during the year.

Academy wins additional e-prescribing exemptions
In response to Academy advocacy initiatives, CMS is providing physicians with an opportunity to apply for a hardship exemption from a 1.5 percent cut to their 2013 Medicare payments if they failed to meet the requirements of its e-prescribing program. The opportunity is available for physicians who have either registered or attested for the Medicare Electronic Health Record Incentive Program. Physicians are able to request a hardship exemption through Jan. 31. Ophthalmologists who qualify for the previously established hardship exemptions (e.g., practicing in a rural area, primarily prescribing controlled substances, or writing fewer than 100 prescriptions) will also have a second opportunity to request an exemption from the penalty that takes effect Jan. 1.

Specialties essentially exempt from 2015 value-based modifier
CMS is required by Congress to adjust physician payments based on their quality and resource use beginning in 2015. The agency will apply the adjustment, known as the value-based modifier, to practices with 100 or more providers in 2015, based on cost data collected next year. Because ophthalmologists generally are affiliated with practices that fall below that threshold, most will be exempt from the value-based modifier. CMS initially proposed to apply the adjustment on groups of 25 or more. As a result of Academy’s lobbying efforts, groups of 100 or more can avoid the -1 percent value-based modifier adjustment entirely by participating in PQRS group reporting.

ASCs to Receive Smaller Increase than Proposed
CMS announced in the 2013 Ambulatory Surgery Center Final Rule, also released today, that ASCs will receive an increase of 0.6 percent beginning Jan. 1. The rule finalizes an ASC conversion factor of $42.917. Details will follow in next week’s Washington Report Express.