OASC | SURGERY

Glaucoma Drainage Surgery: Still Viable for the ASC?

Medicare reimbursement for tube shunt procedures has been reduced significantly.

By Desiree´ Ifft, Contributing Editor

As of Jan. 1, 2015, when a tube shunt procedure is performed with a patch graft, the providers can no longer bill using both CPT 66180 for the aqueous shunt procedure and CPT 67255 for scleral reinforcement. Instead, under the new American Medical Association (AMA) CPT coding instructions, 66180 describes both aspects of the surgery (aqueous shunt to extraocular equatorial plate reservoir, external approach; with graft). “The net effect of this consolidation of two codes, 66180 and 67255, into a single code results in reduced payment: 31% lower for the surgeon and 20% lower for the facility — ASC or hospital outpatient department (HOPD),” says Kevin J. Corcoran, COE, CPC, CPMA, FNAO, president of Corcoran Consulting Group.

As Corcoran explains, prior to this change, the 2014 national ASC payment amount for 66180 was, rounded to the nearest dollar, $1,678, and the national ASC payment amount for the secondary procedure, 67255, was $474, for a total of $2,152. The 2015 national ASC payment amount for 66180 is $1,712. The 2014 Medicare surgeon reimbursement for tube shunt surgery was $1,214 for 66180 and $447 for 67255 for a total of $1,661. In 2015, the surgeon can bill only one code, 66180, for the shunt and the graft, and Medicare payment is $1,152. Coding and reimbursement for tube shunt revision procedures have been changed in a similar fashion. The patch graft can no longer be billed separately with 67255, and the previous code for revision, 66185, is now used for both the revision and the graft. “Again, the net result is a reduction in reimbursement: 34% lower for the surgeon and 55% lower for the facility,” Corcoran says. Although it’s less frequent, a surgeon can perform a tube shunt surgery without a patch graft. The applicable 2015 codes are 66179 (shunt without graft) and 66184 (revision without graft). “Further, the providers can’t use 66179 or 66184 along with the old patch graft code, 67255,” Corcoran cautions. “In all of these tube shunt scenarios, the bottom line is there is now only one code.”

The rationale for the changes? Corcoran says, “AMA asked the American Academy of Ophthalmology to look at these codes, with a little bit of prompting from the Centers for Medicare & Medicaid Services (CMS), and recommend new code descriptors to address the ‘separate procedure’ limitation that was generally ignored during claims processing. Significantly, CMS never issued any constraints within its National Correct Coding Initiative to address this issue, so the Medicare Administrative Contractors always paid these claims for concurrent procedures.”

Crunching the Numbers

The decrease in reimbursement has ASCs across the country taking a close look at how they need to react. “We have to adapt somehow,” says Frank Cotter, MD, a glaucoma and cataract surgeon with Vistar Eye Center in Virginia and co-owner of the Roanoke Valley Center for Sight, an ASC. According to his team’s initial review of their center’s numbers, in 2014 their costs per tube shunt case including supplies and overhead were $673 for 66180 and $765 for 67255 (Totaling $1,438). In 2014, they were reimbursed a total of $2,065. For the same procedure with the same costs in 2015, the total reimbursement is $1,646.

Currently, Dr. Cotter performs all of his tube shunt surgeries at the ASC but he isn’t sure he can continue to do so in light of the reimbursement change. “It just may not be affordable now,” he says. “Essentially, we’re no longer being reimbursed for the patch graft, something we need to use. Tube shunt surgery was already the least profitable procedure performed in our ASC. It’s hard to understand why reimbursement is being reduced further for a complex procedure performed on patients who are facing irreversible blindness.” Dr. Cotter estimates that 40% of the glaucoma surgeries he performs are tube shunts with patch grafts and 60% are filtration procedures, i.e., trabeculectomies and MIGS devices.

Glaucoma Surgery Trends

According to Kevin J. Corcoran, COE, president of Corcoran Consulting Group, use of tube shunts for glaucoma surgery is rising slightly while the number of trabeculectomies performed is diminishing only slightly more. Medicare paid for the following:

Aqueous shunts (CPT 66180)

• 11,111 in 2011

• 12,021 in 2012

• 12,835 in 2013 (most recent data available)

Trabeculectomies (CPT 66170 regular and CPT 66172 complex)

• 19,194 in 2011

• 18,007 in 2012

• 17,729 in 2013 (most recent data available)

An earlier analysis of Medicare claims data by Corcoran showed the number of tube shunt procedures paid for by Medicare rising by 184% from 1995 to 2004 and the number of trabeculectomies in the same time period decreasing by 53%.¹

In the meantime, the types of surgical procedures performed for the treatment of glaucoma has diversified, but a surprising trend has emerged: In totality, the number of glaucoma procedures performed is not increasing. Medicare paid for:

Total number of glaucoma surgeries, including laser procedures:

• 355,277 in 2011

• 354,868 in 2012

• 365,325 in 2013 (most recent data available)

“Although the total number of surgeries for glaucoma is flat,” Corcoran says, “no one is sure why.” His most recent analysis of Medicare claims data related to glaucoma surgery will be published soon in the American Journal of Ophthalmology.

REFERENCE

1. Ramulu PY, Corcoran KJ, Corcoran SL, Robin AL. Utilization of various glaucoma surgeries and procedures in Medicare beneficiaries from 1995 to 2004. Ophthalmology. 2007;114(12):2265-2270.

Potential Next Steps

“One possibility for addressing the shortfall is for surgeons to shift tube shunt procedures from the ASC back to the hospital, where reimbursement rates are still higher than in ASCs,” Dr. Cotter continues. “It’s puzzling why CMS would want to drive patients in that direction.” Certainly, Dr. Cotter would prefer to keep the procedures at the ASC, where the staff members are experienced in ophthalmology, OR turnover time is much faster, and the whole experience, including cost, is better for patients. “The efficiency of the ASC helps me to manage my day better as well,” he notes. “Turnover time is 5 minutes. We have no wasted steps during the procedure because this staff has assisted in more than 1,000 shunts with me. Compared to working at the hospital, I can perform twice as many cases in the ASC per day. That gives me more time to provide care in the clinic. It also helps with my personal bottom line because I can accomplish more in the course of a day.”

Another potential response to the decline in reimbursement, Dr. Cotter suggests, is for surgeons to further explore or revisit alternative surgical techniques that eliminate the need for a patch graft.^1-4 He points to one study in which Ahmed valves were implanted in more than 100 children through a needle-generated scleral tunnel. No graft was used, yet no tube extrusions or exposures occurred.¹ He cites another study, out of Wills Eye Hospital, which showed that an autologous scleral lamellar graft can be effective at preventing tube erosion and graft-related or intraocular complications.³

“We don’t know at this point if these would be workable solutions, but they’re worth considering if they allow us to continue performing tube shunt surgeries in the ASC,” Dr. Cotter concludes. “We can try to increase our efficiency (See “Tips for Efficiency”) but in the end, there’s no magic to this — if we aren’t reimbursed at least a minimum amount for services provided, we can’t be profitable.” ■

References