Currently, very few cataract cases are performed in an office-based surgery (OBS), but interest is growing. Let’s review what you need to know.

Q. Why the interest in office-based cataract surgery?

A. Ophthalmologists in most of the country overwhelmingly choose to do cataract surgery in an ambulatory surgery center (ASC). In some locations there is no ASC available, so the surgeon must do cases at the hospital outpatient department (HOPD). That may limit the number of cases a surgeon can perform because block time is often restricted and turnover is typically slower; this can be problematic for a growing surgical practice.

In states with certificate of need requirements, it may be very difficult to build an ASC. An OBS begins to look attractive. The primary economic problem, under Medicare’s current rules, is that an OBS does not receive reimbursement for a facility fee.

Because 95% of ophthalmologists are participating physicians, the Medicare assignment rules apply to them. The mechanics of Medicare claims processing is unchanged in an OBS. As a result, there are strict limits on what can be reimbursed and the beneficiary’s financial responsibility.

To find revenue to pay for the added cost of OBS, surgeons focus on Medicare noncovered services, such as refractive surgery combined with cataract surgery and premium IOLs for the correction of astigmatism and presbyopia. Because assignment rules do not apply to noncovered items, the beneficiary can be asked to pay for them. Consequently, a surgeon may do some cataract cases in an ASC or HOPD, and only selected cases in-office when they include noncovered elements. There are important medical reasons to differentiate the site of service. For example, cases that require general or regional anesthesia, not just topical, may not be suitable for OBS.¹

Q. Does the surgeon’s fee change?

A. No. Within traditional Medicare (Part B), a surgeon who performs cataract surgery in the office, rather than an ASC or HOPD, receives additional reimbursement only for the IOL. There is no difference in the professional fee reimbursement.

In 2016, CMS considered a pilot project to investigate this topic but did not move forward with it.² Then again in 2023, CMS reviewed a proposal to pay a surgeon a higher professional fee for cataract surgery performed in an OBS than for surgery in a licensed facility such as an ASC or HOPD.³ The proposal was submitted by iOR Partners⁴ and other proponents of office-based surgery for ophthalmology.

CMS decided not to change their current policy and may reconsider at a later time.

Q. Does Medicare reimburse for a surgical tray, an administrative fee or a facility fee?

A. No, and under the Medicare assignment rules, beneficiaries cannot be asked to pay for them out-of-pocket, even if they want to. An Advance Beneficiary Notice of Noncoverage may not be used to charge beneficiaries for covered items.

Anesthesia, of any type, administered by the surgeon is likewise incidental to the surgery and no separate reimbursement is available, nor is the beneficiary financially responsible.⁵

Under existing regulations, traditional Medicare will pay separately for an IOL when implanted in an office setting; in 2023, the amount is about $136.^6-8

Q. How about other payers?

A. At present, very few cataract operations (<1%) are performed in an OBS.⁹ But, at Corcoran Consulting, we have noticed the number is growing. Some subsets of patients are candidates, such as Medicare Advantage and uninsured patients.¹⁰ In light of the CMS limitations, discussions about OBS frequently focus on other third-party payers.¹¹ Commercial payers and Medicare Advantage Plans (Part C) have more latitude to make separate arrangements with individual ophthalmologists for OBS, particularly when a contract covers a large number of beneficiaries.

Q. What are the pitfalls?

A. OBS is not for everyone, for many good reasons. Check the American College of Surgeons for guidance on patient safety guidelines for office-based surgery.¹² The applicable state laws and regulations pertaining to OBS are diverse, and surgeons are advised to consider them carefully. Not surprisingly, some states have heavier regulations than others. OM

REFERENCES

1. Office-Based Surgery FAQ Boston Scientific. January 2014. https://www.bostonscientific.com/content/dam/bostonscientific/Reimbursement/Women%27s%20Health/Office_Based_Surgery_FAQ.pdf . Accessed Sept. 27, 2023.
2. CMS defers action on payment for office cataract surgery. Outpatient Ophthalmic Surgery Society. http://ooss.org/2015/11/03/cms-defers-action-on-payment-for-office-cataract-surgery . Accessed Sept. 27, 2023.
3. CMS-1770-P. Revision to Payment Policies under the MPFS QPP and other revisions to Part B for CY 2023. https://www.cms.gov/medicaremedicare-fee-service-paymentphysicianfeeschedpfs-federal-regulation-notices/cms-1770-p . Accessed Oct. 3, 2023.
4. iOR Partners. www.iorpartners.com . Accessed Sept. 27, 2023.
5. CMS Medicare Claims Processing Manual, Chapter 12, §20.5. Anesthesia by surgeon (modifier 47). https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/clm104c12.pdf . Accessed Oct. 3, 2023.
6. CMS Transmittal 1430, §120.2. Feb 1, 2008. https://www.cms.gov/regulations-and-guidance/guidance/transmittals/downloads/r1430cp.pdf . Accessed Oct. 3, 2023.
7. CMS Transmittal 1228, p. 5, April 27, 2007. https://www.cms.gov/regulations-and-guidance/guidance/transmittals/downloads/r1228cp.pdf . Accessed Oct. 3, 2023.
8. CMS Medicare Vision Services, MLN907165, August 2021. https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/visionservices_factsheet_icn907165.pdf . Accessed Oct. 3, 2023.
9. Medicare physician & other practitioners – by provider and service file, 2021 data. https://tinyurl.com/y684k9u5 . Accessed Sept. 28, 2023.
10. Jubinville M. Surgery at the Doctor’s office: What you need to know. NYU Langone Health, Department of Surgery. https://froemkelab.med.nyu.edu/surgery/content?ChunkIID=14175 . Accessed Sept. 27, 2023.
11. iOR Partners. General Office-Based Surgery FAQs. https://iorpartners.com/knowledge-resources/faqs . Accessed Oct. 10, 2023.
12. American College of Surgeons. Patient safety principles for office-based-surgery. https://www.facs.org/for-patients/patient-resources/patient-safety/office-based-surgery . Accessed Oct. 3, 2023.

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