Office-based surgery (OBS) has become a focal point in the ophthalmic field, gaining significant attention after the Centers for Medicare & Medicaid Services (CMS) addressed OBS in the 2023 Final Rule. This article delves into 10 frequently asked questions surrounding office-based cataract surgery, providing insights into the nuances of Medicare reimbursement. Let’s get started.
Q. Has ophthalmologists’ stance toward OBS evolved over the years?
A. According to iOR Partners, 84% of ophthalmologists opposed OBS in 2016. That number dropped significantly to 39% in 2022.1
Q. What factors contribute to the growing interest in cataract surgery performed in an OBS?
A. Cataract surgery remains a high-volume procedure within the Medicare program, with more than 1.7 million procedures performed by ophthalmologists in 2021.2 Combine this volume with declining reimbursement and increased efficiency from technological advancements, and it’s not surprising that some ophthalmologists and private companies petitioned CMS to establish a facility fee for office-based
surgery.
Q. What are the main concerns for office-based cataract surgery compared to surgeries performed in the ASC or HOPD?
A. Societies such as the Outpatient Ophthalmic Surgery Society vocalized their concerns for OBS during the comment period of the CMS 2023 Final Rule.3 Some of the concerns included sterility control, changes in anesthesia protocols, and equipment quality and maintenance.
Q. What possible advantages are associated with cataract surgery performed in an OBS?
A. OBS may offer increased flexibility and efficiency for both the surgeon and the patient in terms of scheduling as well as cost. Having access to an OBS suite eliminates the need to schedule into a dedicated block at the ASC/HOPD as well as the associated facility fees.
Q. How does place of service (POS) impact physician reimbursement?
A. Currently, the Medicare physician fee schedule’s Relative Value Units (RVUs) for cataract surgery do not differentiate between facility (ASC/hospital) and non-facility (office) services. In other words, physician reimbursement is the same regardless of place of service.
Q. Will the practice receive reimbursement for supplies and other expenses when conducting procedures within the OBS?
A. If a physician performs traditional, covered cataract surgery in the office, there is no additional reimbursement to cover overhead, supplies, instruments, etc. In contrast, when the procedure is performed in a facility, the facility submits a claim and receives reimbursement for such costs separate from the surgeon’s reimbursement.
Q. What is the 2024 National physician reimbursement for cataract surgery, and what does it include?
A. The 2024 National physician rate for routine cataract surgery (66984) is $528.49.4 That rate combines physician work, practice expense and malpractice expense. The rate does not consider the added costs such as supplies, equipment, staff, etc, associated with cataract surgery.
Q. If physicians perform office-based cataract surgery, can they be reimbursed for the IOL?
A. When surgery is performed in a hospital or ASC, “Payment for the IOL is packaged into the payment for the surgical cataract extraction/lens replacement procedure.”5 However, because CMS does not provide additional reimbursement for OBS services, the surgeon may charge for a standard IOL.
According to the Medicare Claims Processing Manual, Chapter 32§120.2, “…physicians inserting a P-C IOL or A-C IOL in an office setting may bill code V2632 (posterior chamber intraocular lens) for the IOL. Medicare will make payment for the lens based on reasonable cost for a conventional IOL.”6 The Cataract Surgery Coding Guidelines from Medicare Administrative Contractor WPS Health Systems confirm that supply code V2632, posterior chamber intraocular lens, should be submitted on the claim along with cataract surgery (CPT 66984/66982).7
Q. What is the reimbursement for the IOL placed in the OBS?
A. The Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) fee schedule lists the October 2023 National Rate for V2632 at $135.98,8 which is considerably less than the 2024 National ASC facility payment of $1183.749 for cataract surgery (CPT 66982/66984) listed by CMS.
Q. What is CMS’s current stance on office-based surgery?
A. After reviewing the comments within the 2023 proposed rule in favor of and against establishing a payment rate for OBS, CMS stated, “... we will continue to gather information concerning Cataract and Retinal Surgeries in the non-facility office settings and their implications to Medicare payment for future rulemaking.”10
KEEP AN EAR TO THE GROUND
Exploring the realm of office-based cataract surgery raises critical questions and considerations for ophthalmologists navigating the ever-evolving landscape of health care. As CMS continues to gather information for future rulemaking, it becomes imperative for ophthalmologists to carefully weigh the pros and cons, considering factors such as the intricate details of office-based reimbursement. The evolving nature of CMS regulations and the ongoing dialogue within the medical community underscore the necessity for a nuanced approach when determining if OBS is the right fit for your practice. OM
References
1. CMS Continues to Evaluate Ophthalmic Office-Based Surgery Reimbursement. iOR Partners. https://iorpartners.com/cms-continues-to-evaluate-ophthalmic-office-based-surgery-reimbursement. Accessed Dec. 18, 2023.
2. 2022 Physician/Supplier Procedure Summary. Data.CMS.gov. http://tinyurl.com/yvnfjfud. Accessed Jan. 11, 2024.
3. CMS Proposed Rule 2023. Centers for Medicare and Medicaid Services. https://www.govinfo.gov/content/pkg/FR-2022-07-29/pdf/2022-14562.pdf. Accessed Dec. 18, 2023.
4. CMS 2024 Medicare Physician Fee Schedule. The Centers for Medicare and Medicaid Services. https://www.cms.gov/medicare/medicare-fee-service-payment/physicianfeesched/pfs-federal-regulation-notices/cms-1784-f. Accessed Dec. 18, 2023.
5. Medicare Claims Processing Manual Chapter 32 – Billing Requirements for Special Services. https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/clm104c32.pdf. Accessed Dec. 18, 2023.
6. Medicare Claims Processing Manual Chapter 32 – Billing Requirements for Special Services. http://tinyurl.com/2pfd4v7t. Accessed Dec. 18, 2023.
7. Cataract Surgery Coding Guidelines. WPS Government Health Administrators. https://med.wpsgha.com/search?q=cataract+surgery. Accessed Dec.18, 2023.
8. DMEPOS Fee Schedule Files. Centers for Medicare and Medicaid Services. https://www.cms.gov/medicare/payment/fee-schedules/dmepos/dmepos-fee-schedule. Accessed Dec.18, 2023.
9. CMS 2024 Ambulator Surgery Center Fee Schedule. Centers for Medicare and Medicaid Services. http://tinyurl.com/54abn4pw. Accessed Dec. 18, 2023.
10. CMS 2023 Medicare Physician Fee Schedule Final Rule. Centers for Medicare and Medicaid Services. https://www.federalregister.gov/documents/2022/11/18/2022-23873/medicare-and-medicaid-programs-cy-2023-payment-policies-under-the-physician-fee-schedule-and-other. Accessed Dec. 18, 2023.
