As the end of the year approaches, ophthalmic practices must thoroughly prepare to ensure a smooth transition into the upcoming year. This preparation should involve several steps, including reviewing fee schedules from Medicare and other payers, examining local coverage determinations (LCDs) and local coverage articles (LCAs), as well as reviewing policy changes from private payers and fulfilling end-of-year reporting requirements for the Merit-Based Incentive Payment System (MIPS).

By addressing these essential tasks, your practice can optimize its operations, financial health and compliance with regulatory requirements. Strategically prepare for the new year with the steps below.

REVIEW FINAL RULE AND FEE SCHEDULE CHANGES

One of the most crucial aspects of preparing your ophthalmic practice for the new year is reviewing fee schedules and Final Rule updates. This ensures that your practice’s financial health remains intact and that you are billing accurately for your services.

The Final Rule, which contains the Medicare Physician Fee Schedule (MPFS), was released by CMS on Nov. 2. However, in previous years, Congress stepped in and changed the MPFS in late December after much lobbying by concerned stakeholders.¹ Practices should check for any updates to the Current Procedural Terminology (CPT) codes. It’s also important to review the reimbursement rates for ophthalmic services, as several services have changes in Relative Value Units (RVUs) for 2024,² so make sure to stay informed and adjust your billing accordingly.

In addition to Medicare, review fee schedules from private payers who typically make changes to their reimbursement rates, coding guidelines or billing policies more frequently than CMS; signing up for alerts from your third-party payers is beneficial and will help you stay informed throughout the year.

PREVENT REVENUE LOSS

Ensure that your practice is current with these changes to prevent revenue loss. Verify that your coding practices are accurate and current by continuing or implementing an internal auditing process.

Review the documentation and claim submission for any new CPT codes before sending them out to verify accuracy. Incorrect coding can lead to claim denials or audits, resulting in undue time and financial burdens for the practice.

CONSULT THESE GUIDES

Local Coverage Determinations and Local Coverage Articles

LCDs and LCAs play a significant role in determining coverage and reimbursement for ophthalmic procedures and diagnostic testing. They often provide detailed information on covered indications, medical necessity documentation requirements and coding guidance for specific procedures. These documents are created by Medicare Administrative Contractors (MACs) and guide how specific services are covered within your geographic region.

Practices should check their local MAC’s LCDs/LCAs for any updates or revisions applicable to their respective specialties. These changes may affect coverage criteria, documentation requirements and billing practices.

For instance, several MACs are in the process of reviewing comments from a draft policy period about minimally invasive glaucoma surgery (MIGS) coverage changes. If these policies go into effect, many widely accepted glaucoma surgeries will be considered “investigational” and, therefore, non-covered. Some of the procedures up for coverage revision include, but are not limited to: goniotomy, ab interno canaloplasty and cyclophotocoagulation.³

Even if your subspecialty does not appear to be impacted by any updates, read and review current policies to ensure you are not missing any documentation requirements.

Third-party payer policies

It’s also crucial that practices review third-party payer policies. United Health Care recently implemented a similar stance to the MAC draft policies. The glaucoma policy dated Oct. 1, 2023, indicates canaloplasty, goniotomy and several other procedures are “unproven” and “not medically necessary.”⁴ In June 2023, Cigna delayed (to an unknown future date) its implementation of a requirement to include documentation to support modifier 25 with each submission.⁵ Also, Blue Cross Blue Shield of Illinois updated their Wasted/Discarded Drugs and Biologicals Policy to include the new JZ modifier.⁶

If payer policies contain new or updated requirements, ensure your staff is educated and trained accordingly. This may involve conducting training sessions, updating your practice’s policies and procedures and ensuring your EHR system accommodates the necessary changes.

END-OF-YEAR MIPS REPORTING

Several issues require consideration when fulfilling end-of-the-year MIPS reporting requirements and planning for a successful new reporting year. MIPS (or Traditional MIPS) assesses clinician performance based on various quality measures, using certified EHR systems to promote interoperability and information exchange, practice improvement activities and cost of care to Medicare.

Collect and maintain accurate data on the measures and activities relevant to your practice. Ensure that you have documentation supporting your performance throughout the year. For example, if your practice has chosen the “Expanded Practice Access” Improvement Activity, ensure that you have documentation supporting that your physician(s) was available for urgent and emergent care outside of the practice’s standard business hours of operation, utilizing a certified EHR. Typically, this could be achieved via a chart note with a timestamp showing that the doctor examined and/or treated a patient either in the evening or on the weekend.

Note: this measure must be completed for 50% or more of your physicians if in a group practice.⁷

Assess your practice’s performance against MIPS requirements and identify areas for improvement. This self-assessment will help you strategize for the next reporting year. Determine your reporting mechanism, such as through the AAO’s qualified IRIS registry, which is a member benefit. Stay aware of MIPS reporting deadlines. The submission window opens Jan. 2, 2024, and closes on April 1, 2024.⁸ Missing these deadlines, as well as poor performance of measures, can result in penalties of up to 9% of your Medicare reimbursements for a 1-year period. It’s also important to remember that MIPS payments occur 2 years after each performance year. Consider seeking assistance from a health-care consultant or a MIPS reporting specialist if you find MIPS reporting challenging or if your practice is struggling to meet the requirements.

A SUCCESSFUL NEW YEAR

Preparing your ophthalmic practice for the new year is a multifaceted process that involves careful attention to financial, regulatory and performance-related details. By reviewing fee schedules from Medicare and private payers, staying informed about coverage changes through reviewing LCDs/LCAs and private-payer policies, and fulfilling final MIPS performance requirements, your practice can ensure its financial stability and maintain required compliance. Proper preparation will not only benefit your practice but enhance the quality of care you provide for your patients, contributing to the success and sustainability of your ophthalmic practice in the coming year and beyond. OM

REFERENCES

1. Consolidated Appropriations Act, 2023. https://www.appropriations.senate.gov/imo/media/doc/JRQ121922.PDF . Accessed October 19, 2023.
2. Proposed Rule CY 2024. https://public-inspection.federalregister.gov/2023-24184.pdf . Accessed October 18, 2023.
3. Noridian Healthcare Solutions, LLC Draft MIGS LCD. https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=39600 . Accessed October 18, 2023.
4. United Health Care Glaucoma Policy. https://www.uhcprovider.com/content/dam/provider/docs/public/policies/medicaid-comm-plan/glaucoma-surgical-treatments-cs.pdf . Accessed October 19, 2023.
5. Cigna Modifier 25 Policy. https://static.cigna.com/assets/chcp/secure/pdf/resourceLibrary/clinReimPolsModifiers/Notifications/Modifier_25_Significant_Separately_Identifiable_Evaluation_and_Management.pdf . Accessed October 19, 2023
6. Blue Cross Blue Shield of Illinois JW/JZ Modifier Policy. https://www.bcbsil.com/docs/provider/il/standards/cpcp/cpcp017-01302023.pdf . Accessed October 19, 2023.
7. Quality Payment Program Explore Measures & Activities. https://qpp.cms.gov/mips/explore-measures?tab=improvementActivities&py=2023 . Accessed October 19, 2023.
8. Quality Payment Program Deadlines. https://qpp.cms.gov/resources/deadlines . Accessed October 18, 2023.

Brittney Irwin, COT, CPC-A, CEP, is a consultant within the Billing, Coding and Compliance Division of BSM Consulting. In her role, she provides ongoing billing and coding support to ensure ophthalmic regulatory compliance. Previously, she spent more than 10 years working in ophthalmology, most recently as the clinical director of a multi-specialty group.

Laurie K. Brown, MBA, COMT, COE, CPC, CPMA, LSSYB, is a senior consultant with BSM Consulting in Tucson, Ariz. She has experience in the ophthalmic industry holding managerial, clinical and surgical roles for more than 30 years.