Coding

Ring in the old, the new — and the reduced

Many important coding changes are en route for 2015.

By Suzanne Corcoran

Ophthalmology practices survived 2014, although the year had its challenges. The administrative burdens of PQRS and meaningful use, just to name two, distracted many from other practice priorities, like management itself. With 2015 now upon us, expect these challenges to continue and new ones to appear that will affect all aspects of your practice. Let’s look at some of the more significant ones (For a rundown on changes to the CPT coding manual, see Sidebar, page 18).

THE BIG QUESTIONS

Q. What changes can we expect to physician reimbursement?

A. Efforts to eliminate the flawed Sustainable Growth Rate (SGR) formula continue. The SGR Repeal and Medicare Provider Payment Modernization Act (H.R. 4015/S.2000), which would repeal the SGR, would also institute a 0.5% update to Medicare physician payments for five years, and preserve fee-for-service payments. The act would also create a new, non-budget-neutral, Merit-based Incentive Payment System. The bill failed to pass in 2014 so the process restarts in 2015.

The Protecting Access to Medicare Act (PAMA) 2015 preserves a 0% physician fee schedule update for Jan.1 to March 31, 2015. The Nov. 13, 2014, Federal Register included the final rule for the MPFS and other Medicare Part B payment policies. The conversion factor changes slightly from $35.8228 to $35.8013. If Congress does not intervene prior to April 1, the SGR drops the conversion factor to $28.2239, effective for services performed April 1 to Dec. 31, 2015. Additionally, Relative Value Unit (RVU) changes took place Jan. 1, so the fee schedule for the first quarter of 2015 is not just a continuation of 2014. And CMS corrected an error in the malpractice RVUs, which results in about a 1% to 2% reimbursement reduction for ophthalmology.

The result? Again, we will have more than one Medicare Physician Fee Schedule (MPFS) in 2015. We expect a net reduction of 2% to 5% overall for ophthalmology in 2015, not counting a possible SGR cut.

The big losers are mostly retina:

• Intravitreal injection (67028) is reduced by about 3%

• PPV (67036) is reduced 9%

• PPV with removal of ILM (67042) is reduced 26%

• PPV with endolaser PRP (67040) is reduced 29%

• SCODI retina (92134) is reduced 2%.

Cataract surgery will drop by about 4%. The comprehensive eye exam for established patients (92014) also took a small hit, about 1%, but the blow is softened as this code is billed frequently

Also included in the final rule is a plan to transition away from global surgery packages. Minor surgery 10-day global periods expire in 2017; 90-day global periods expire in 2018. Medically reasonable and necessary visits, both pre-op and post-op, would be billed separately. Ophthalmic specialty societies oppose this approach and are working with CMS to delay implementation until more information is available.

Q. Are there diagnostic code changes?

A. CMS did not publish new ICD-9 codes in anticipation of ICD-10 implementation on Oct. 1, 2015. There are also no changes to ICD-10 in 2015.

Q. What about ASC and HOPD reimbursement?

A. For 2015, the wage adjustment for budget neutrality, added with the multifactor productivity adjusted update factor, raises the ASC conversion factor by 1.4% for ASCs meeting the quality reporting standards. This means small increases in facility reimbursement.

Various adjustments to hospital reimbursement result in a hospital outpatient department (HOPD) rate increase of 2.3%.

Q. What are Medicare auditors looking at in 2015?

A. The annual publication of the Office of Inspector General Work Plan published a series of initiatives that will continue in 2015. While no new initiatives appear pertinent to ophthalmology, the returning targets for scrutiny include:

• Place of service errors

• Payments for drugs

• Ambulatory surgical centers – Payment system

• Ophthalmological Services – Questionable billing during 2012

• Imaging services – Payments for practice expense

• Medicare incentive payments for adopting electronic health records

• Anesthesia services – Payments for personally performed services

• Payment for compounded drugs under Medicare Part B

• Security of Certified Electronic Health Record Technology under Meaningful Use

Total corrections since the Medicare Fee-for-Service Recovery Audit Program began in October 2009 stand at $7.26 billion, including $6.8 billion in overpayments.

Q. Are there changes to PQRS in 2015?

A. The Patient Protection and Affordable Care Act made the Physician Quality Reporting System (PQRS) mandatory in 2015. Eligible professionals who did not successfully report PQRS in 2013 will be penalized 1.5% off the MPFS in 2015. Providers who did not successfully report in 2014 will be penalized 2% in 2016.

Q. Did ophthalmologists earn any EHR bonus money?

A. As of September 2014, the Electronic Health Record Incentive Bonus Program paid out $6.47 billion to eligible providers; $187 million to ophthalmologists and $261 million to optometrists. Requirements continue to challenge practices.

CMS granted a reprieve to providers expected to attest to Stage 2 requirements for 2014. Most reported Stage 1 objectives and measures for 2014 and will move forward with Stage 2 in 2015. Meaningful use reporting in 2015 requires full-year participation for anyone beyond year-one reporting. For those who did not qualify for a hardship exemption or complete their meaningful use attestation for Stage 1 by October 1, 2014, a penalty of 1% off their MPFS applies for 2015.

Q. What changes are taking place for patients?

A. Not many. The Medicare Part B premiums remain $104.90 for most beneficiaries. The Part B deductible also remains at $147. These beneficiary costs are unchanged from 2013 and 2014. OM

Suzanne L. Corcoran is vice president of Corcoran Consulting Group. She can be reached at (800) 399-6565 or www.corcoranccg.com.