Coding & Reimbursement

2016 bulletin on fee schedules, codes

Glaucoma and retina take most of the hits.

By Suzanne L. Corcoran

The new year, of course, brings changes to the coding landscape. This month, we will look at changes to the Medicare fee schedules, as well as coding changes for 2016.

Q. What happened with the Medicare Physician Fee Schedule as of Jan. 1?

A. Most codes have no changes at all, while many more experience a 1% increase or decrease.

Overall, ophthalmology experienced approximately a 1% reduction. The largest decreases mainly affect glaucoma and retina. Some examples of percentage changes from 2015:

• Probing NLD (68810) -19%

• Trabeculectomy (66170 & 66172) -19%

• Trabeculoplasty (65855) -19%

• Complex RD repair (67113) -23%

• RD repair (67108) -32%

• Destruction retinopathy, cryo (67227) -52%

• Treatment of retinopathy, PRP (67228) -66%

Revisions to CMS’ implementation of fee schedule changes require that large reductions be phased in over two years, so cuts in 2016 to 67113 and 67108 will be 19% rather than the larger percentages shown; additional reductions will take place in 2017.

CPT codes 67227 and 67228 are expected to change from 90-day to 10-day global periods. If this happens, they will likely take the full brunt of the fee reductions in 2016 rather than be phased in.

Q. What about ambulatory surgery center facility fees in 2016?

A. For 2016, ASCs get a 1.3% increase. However, the increase only applies to ASCs that successfully reported quality measures; most ophthalmic ASCs did. Those that did not will get a 2% reduction instead.

Q. Did hospital outpatient departments (HOPDs) get increases similar to ASC facility rates?

A. No. Various adjustments to hospital reimbursement result in a HOPD rate decrease of -0.3%.

Q. What about coding changes in 2016?

A. There were several, including one new Level I CPT code:

• 65785 – Implantation of intrastromal corneal ring segments. This replaces the Category III code, 0099T

The new year also brings three revised codes. For each of these, the “one or more sessions” verbiage was removed.

• 65855 – Trabeculoplasty by laser surgery

• 67227 – Destruction of extensive or progressive retinopathy (eg, diabetic retinopathy), cryotherapy, diathermy

• 67228 – Treatment of extensive or progressive retinopathy (eg, diabetic retinopathy), photocoagulation

The following codes contain language changes. These changes do not affect reimbursement (additional verbiage in bold).

Δ 67101 – Repair of retinal detachment, one or more sessions; cryotherapy or diathermy, including drainage of subretinal fluid when performed

Δ 67105 … photocoagulation including drainage of subretinal fluid, when performed

Δ 67107 – Repair of retinal detachment; scleral buckling (such as lamellar scleral dissection, imbrication or encircling procedure), including, when performed, implant, cryotherapy, photocoagulation and drainage of subretinal fluid

Δ 67108 … with vitrectomy, any method, including, when performed, air or gas tamponade, focal endolaser photocoagulation, cryotherapy, drainage of subretinal fluid, scleral buckling, and/or removal of lens by same technique

Δ 67113 – Repair of complex retinal detachment … with vitrectomy and membrane peeling including, when performed, air, gas, or silicone oil tamponade, cryotherapy, endolaser photocoagulation, drainage of subretinal fluid, scleral buckling and/or removal of lens

Δ 99174 – Instrument-based ocular screening (eg, photoscreening, automated-refraction), bilateral; with remote analysis and report

One code was deleted in 2016:

• 67112 … by scleral buckling or vitrectomy on patient having previous ipsilateral retinal detachment repair(s) using scleral buckling or vitrectomy techniques

There is one new Category III code:

• 0402T – Collagen cross-linking of cornea (including removal of the corneal epithelium and intraoperative pachymetry when performed)

(Do not report 0402T in conjunction with 65435, 69990, 76514)

Finally, CMS revised one Category III code:

Δ 0308T – Insertion of ocular telescope prosthesis including removal of crystalline lens or intraocular lens prosthesis

Coverage and payment for Category III codes remains at the discretion of the Medicare Administrative Contractor (MAC).

Q. Were there any changes to diagnosis codes or issues with the implementation of ICD-10?

A. There are no new ICD-10 codes. Since implementation on Oct. 1, 2015, the ICD-10 transition has been relatively smooth. Contractor policies occasionally missed ICD-10 codes that didn’t translate correctly from ICD-9 coverage lists. Any denials due to this issue should be brought to the attention of the payer and appealed. OM

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