In our perpetual fight for vision, most seasoned ophthalmologists have learned how to take a few punches from Medicare. Physician reimbursement on a variety of commonly utilized procedure and visit codes has been slowly and incrementally eroded over the years at the hands of the Centers for Medicare and Medicaid Services (CMS). However, none of CMS’s blows have had a greater impact on ophthalmologists than cuts in cataract surgery reimbursement.

As the most commonly performed outpatient procedure in ophthalmology, not to mention medicine in general,¹ cataract surgery has served as the lifeblood for physicians and their practices while simultaneously serving as a major target for CMS in the ongoing struggle for budget neutrality. Physician reimbursement for cataract surgery has already incrementally fallen to a value approximately one-third of the amount paid in the 1980s.² And now in 2020, we will again face another significant decline in payment. How much will CMS’s latest edict impact cataract surgeons, and what can we do to withstand the cuts?

WHAT’S COMING IN 2020?

A look at the numbers

Per the proposed payment rule, reimbursement for non-complicated cataract surgery (CPT code 66984) will drop from the current level of $654 down to an estimated $557, and complex cataract surgery (CPT code 66982) will also fall from $813 in 2019 to an estimated $766 starting Jan. 1, 2020. This represents a 15% and 6% reduction in payment, respectively. These rates are based on the recommendations of the AMA’s relative value update committee (RUC), which is tasked with determining the effort and resources necessary to perform a procedure. Based on a host of factors, including surgeon survey data, the RUC assigns work relative value units (RVUs) for each code. The drop in RVUs was primarily based on the number of postoperative visits decreasing from four to three, along with a 10% decrease in estimated operating time. In a way, by becoming more efficient at such a complex and intense surgery, we have become victims of our own success.

What it means for you

For a surgeon who performs an average of 300 cataract surgeries a year with 10% of these being complex, this amounts to $27,577 less revenue compared to 2019. A surgeon performing ~900 cases a year would see a drop of more than $80,000 vs. the previous year. Looking at it another way, about one in every seven cataract procedures performed will not be reimbursed compared to what was received in 2019. Perhaps these cuts would be more palatable if the cost to perform phacoemulsification or to run a practice were also decreasing, but most ophthalmologists report EMR and equipment costs are only climbing.

If there is any solace in the face of this cut, it may be the fact that cataract surgery remains one of the most highly valued procedures based on time. Minute-for-minute cataract surgery reimbursement is estimated to be higher than reimbursement for major operations such as coronary artery bypass, carotid endarterectomy and craniotomy. Still, no matter how you look at it, these cuts are going to hurt.

WHAT YOU CAN DO

Coming soon

With significant cuts only days away, what can eye surgeons do to adapt and find ways to make up this lost revenue? Here are a few ways for practices to help close the gap.

Offer premium cataract services

Perhaps the highest yield way to improve practice revenue from cataract surgery is to adopt and provide premium, cash-pay services in conjunction with surgery. A growing number of options are available to meet patient expectations. Offering non-covered services, such as presbyopia- and astigmatism-correcting IOL technology, can serve to meet the high visual demands of today’s cataract patients while simultaneously providing a revenue boost to providers. A growing number of modern IOL offerings include bifocal, trifocal and enhanced depth of focus optics, with most available in toric models as well. Femtosecond laser platforms offer the potential to correct lower levels of astigmatism through limbal relaxing incisions. Intraoperative aberrometry can be utilized in post-refractive surgery eyes to provide additional accuracy in IOL selection in these patients.

As part of our efforts to improve patient outcomes, all of these can be offered to Medicare patients for an additional charge, as they are non-covered services. Furthermore, practices can set the rates for these premium cataract options to an equitable market level for patients without fear or risk of further devaluation by outside sources. This can serve to insulate providers from additional reimbursement cuts in the future as well. Patient education, advertisements and referral education can help bolster uptake. And offering alternative and flexible financing options for these elective services can further enable greater utilization within the practice. Some examples include low or zero interest financing through independent companies like CareCredit or GreenSky, use of flexible spending account funds and credit cards for payment.

Adopt MIGS

Cataract surgery provides an opportunity to treat glaucoma with minimally invasive procedures that can enhance care on multiple levels. Aside from the ever-present fear of irreversible blindness, these patients more commonly face the daily grind of topical eyedrops (and their accompanying side effects), cost burden and annoyance of chronic daily administration. Micro-invasive glaucoma surgery (MIGS) and angle-based procedures offer patients an opportunity to reduce or eliminate the need for medications at the time of cataract surgery, while also lowering eye pressure. These procedures typically add only a few minutes to procedure time, utilize existing corneal phacoemulsification wounds and minimally affect vision recovery or refractive outcomes for patients.

Adopting one or more of these novel procedures, such as trabecular meshwork (TM) bypass stents, canaloplasty, goniotomy procedures and/or cyclophotocoagulation, can provide significant value for patients, and they are now generally reimbursed by Medicare as well. And, just as patient’s expectations for visual outcomes are higher, they also are increasingly keen on addressing two problems at once while improving quality of life. Fortunately, a glaucoma fellowship is not required to perform these procedures; the majority of ophthalmologists who perform cataract surgery can be trained to implement MIGS as part of their surgical offering. While additional follow-up visits for mild postoperative issues may sometimes be necessary, the follow-up care and visit schedule are typically similar to phaco alone.

Take care to understand the reimbursement environment for category III codes (0191T for example, used by TM bypass stents) in your specific region, as this can vary dramatically across the country. Procedures such as goniotomy, canaloplasty and cyclophotocoagulation are covered by category I codes, however, and are relatively uniform across the United States.

With so many safe and effective minimally invasive surgical options, glaucoma patients can now benefit from addressing their disease at the time of cataract surgery. A helpful secondary outcome, this also assuages the impact of reimbursement cuts on standalone cataract surgery.

Improve surgical efficiency

Despite major improvements in surgical efficiency over the years, surgeons and their ASCs can still seek out additional enhancements that can further improve their bottom line. Potential areas for improvement include proper preparation for every case by ensuring IOL selections have been made and are ready, as well as standard equipment is available and set up. Additionally, staff should be educated on cases that may require additional devices, such as trypan blue, pupillary expansion devices or capsular tension rings, to complete.

On the scheduling side of things, make an effort to minimize cancellation rates and order procedures in a manner that facilitates rapid turnover with minimal equipment changes between cases. Maximizing efficiency also allows the opportunity to bring in additional patients and make up for lost revenue with increased volume. Running the numbers, a surgeon currently performing 15 standard cataracts a day would need to add about 2.5 additional cases per day on average to maintain current revenue stream.

Finally, we feel it is critical to note that surgeons have a tendency to vocalize their intraoperative speed and, at the same time, downplay the complexity of procedures and skills needed to safely restore vision to patients. The periodic CMS surveys that explore surgical time and postoperative effort require thoughtful attention. View them as an opportunity to educate others on the importance of our training and the need for support to deliver optimum care.

Maximize clinical efforts

For many practices, the most practical way to make up lost surgical revenue is not in the operating room but in the clinic. Particularly for doctors performing only a handful of cataracts per month, the time, resources and effort dedicated to handling a small number of cases may fall short of the revenue that could be generated from office visits, diagnostic testing or other surgical procedures. As reimbursement slowly evaporates, each additional minute in the operating room needed to finish one case makes cataract surgery less and less profitable. For example, a surgeon performing one cataract surgery per hour including turnover ($557) could make more by seeing five clinic patients in that hour (5 x $130 = $650). If you factor in diagnostic testing, such as gonioscopy, optical coherence tomography or fundus photography, then the difference only widens.

These practices may be better off taking measures to increase clinical practice profitability rather than trying to increase surgical volume. Some straightforward ways to accomplish this include decreasing no-show rates, minimizing costly coding errors and negotiating stronger contracts with existing plans.

Your EMR can also be harnessed to identify patients lost to follow-up, overdue for diabetic eye exams or in need of glaucoma screening exams and diagnostic testing. Using EMR timestamp data to optimize schedule templates has been shown to not only reduce wait times for patients but also shorten average visit times and enable up to three additional clinic visits per half day.³

WE’VE BEEN THROUGH THIS BEFORE

There’s no way around it: The impending cuts to cataract surgery reimbursement are going to be difficult for surgeons and their practices to absorb. Despite the relentless erosion, we have historically found ways to trim expenses and maximize profits, becoming leaner and more efficient in the process. Surely the latest challenge is no exception.

With continued effort and exploration for alternative revenue opportunities, physicians can work to fill in the gaps and maintain practice and career viability. OM

REFERENCES

1. Moriarty A. Top 10 outpatient procedures at surgery centers and hospitals. Definitive Healthcare. Oct. 3, 2016; updated May 22, 2019. https://blog.definitivehc.com/top-10-outpatient-procedures-at-ascs-and-hospitals . Accessed Oct. 21, 2019.
2. Lichter PR. Payment data and the “me” in Medicare. Ophthalmology. 2014;121:1849-1851.
3. Hribar MR, Huang AE, Goldstein IH, et al. Data-Driven Scheduling for Improving Patient Efficiency in Ophthalmology Clinics. Ophthalmology. 2019;126:347-354.

About the Authors

Leonard K. Seibold, MD, is an associate professor and co-director of the glaucoma fellowship at the University of Colorado School of Medicine. Email him at leonard.seibold@cuanschutz.edu.

Malik Y. Kahook, MD, is professor of ophthalmology and the Slater Family Endowed Chair in Ophthalmology at the University of Colorado School of Medicine. He is vice chair of translational research and serves as chief of glaucoma service and co-director of the glaucoma fellowship at the University of Colorado Eye Center. Email him at malik.kahook@cuanschutz.edu.

Disclosures: Dr. Seibold reports consultancy to Allergan, New World Medical and Sensimed.
Dr. Kahook reports patent royalties from Alcon, Fluent Ophthalmics, Johnson & Johnson Vision, New World Medical, ShapeTech and SpyGlass Ophthalmics.