With virtually every major advance in medicine, there are early adopters who lead the way and skeptics who eventually follow. Office-based surgery (OBS) is a prime example of this classic paradigm.
OBS is closely mirroring the transition from hospital-based surgery to ASC-based surgery, and it has emerged at precisely the right time. With the demand for cataract surgery growing thanks to aging baby boomers, volume is expected to reach 6 million procedures annually in the United States by 2030.1 This trend highlights the pressing need for scalable and cost-effective solutions. Cataract surgery is on track to exceed the capacity of ASCs, which leaves OBS poised to carve out a substantial niche in the ophthalmic surgery landscape.
While many practices might choose to wait to get involved in OBS, others such as ClearSight, where I am the medical director, adopted OBS relatively early. OBS gives us an advantage with respect to being able to offer our patients the convenience of having their surgery performed in a familiar practice while being attended to by the staff with whom they have a preexisting rapport.
By the same token, being an early adopter endows me with a responsibility to share what I’ve learned so that others who are evaluating OBS can be better informed, and that is the purpose of this article.
PRACTICE BACKGROUND
ClearSight is a 30-year-old practice. I joined a decade ago and took on the role of medical director in 2018. We are a team of four surgeons and two optometrists, operating from two locations: our primary site in Oklahoma City and our branch in Plano, Texas, which opened last year. We originally specialized in radial keratotomy and laser vision correction but expanded our services about 10 years ago to include lens-based surgeries, such as implantable collamer lenses and refractive lens exchange. Initially, we performed these surgeries in ASCs, which proved to be costly and a lesser patient experience than our clinic. When we considered investing in an ASC, the terms were unfavorable, so we looked into OBS.
After the onset of the COVID-19 pandemic, we decided to build our own OBS center, which is a suite located within our practice specifically equipped for ophthalmic surgical procedures (Figure 1). We made this decision as ASCs were in the process of being purchased by private equity in our community, and scheduling procedures and maintaining a premium experience were both becoming more challenging. We accomplished this with the assistance of iOR Partners, a company dedicated to getting OBS suites up and running and then providing ongoing assistance with things such as accreditation and billing, as well as other administrative tasks.
Based on our positive experience with our first OBS site, we built a second one last year.
OBS BENEFITS
Greater control
Adopting OBS brings many inherent benefits. It gives us control over cost management, patient care and, ultimately, the entire patient experience. This includes the ability to choose our OR times and make decisions regarding which equipment to purchase. Importantly, we enjoy these benefits with confidence knowing that OBS lens-based surgery is as safe as lens-based surgery in an ASC or hospital.2
Regarding finances, we achieved this in a cost-effective manner: An ASC can cost upward of $2.5 million to $3 million compared with $250,000 to $300,000 for an OBS suite, according to iOR Partners.
Premium lens volume
Another benefit is that OBS is helping grow our premium lens volume and revenue. Patients upgrade to a premium lens because they want a better outcome, but their out-of-pocket expenditure comes with other demands, as well. They are paying for more than the lens and the surgery — they are paying for the experience. They want to feel cared for and have their procedure performed in a modern, aesthetically pleasing environment. Our carefully appointed OBS suites along with our attentive staff satisfy those needs.
Since offering this experience for premium lens patients in our OBS, we have seen a substantial increase in word-of-mouth referrals. This allowed us to grow around 20% year over year.
Having control over all of the elements allows us to offer a better value proposition to our patients. First, they are able to have their procedure in the same location rather than navigating another system. Second, scheduling is simpler and more straightforward. Finally, we create a spa-like experience, allowing patients to feel like they were receiving an even higher value.
While OBS overhead costs are comparable to an ASC, the cost of development is significantly less, so the time to revenue is much quicker. These savings can be reinvested in the practice and/or be transferred to patients in the form of competitive pricing, particularly relevant for premium IOLs, which are usually not covered by third-party insurers.
With procedures performed in an ASC, patients may receive separate bills for the IOL, the facility, the anesthesiologist and any additional fees, which can cause significant confusion. However, when surgeries are conducted in an OBS setting, patients often receive a more comprehensive estimate that includes all aspects of the cataract surgery — diagnostic exams, advanced technology lenses, laser treatment, anesthesia and other costs — bundled into a single package.
REIMBURSEMENT DISTINCTIONS
The greatest misconception about OBS is that surgeons don’t receive Medicare reimbursement. The truth is while OBS surgeons don’t receive a Primary-National Medicare reimbursement, they do receive a Secondary-Local Medicare reimbursement based on local Medicare Administrative Contractors (MAC) codes (Figure 2).
This may sound daunting because it is different from what most surgeons are accustomed to, but OBS surgeons do not have to be coding experts. As part of its ongoing assistance, iOR Partners acts as a coding expert for its clients. The company developed a compliant code-sharing method that is used to ensure that all aspects of the care provided to patients in an OBS facility are appropriately documented and reimbursed. Known as “Code-Set Billing,” this process has been audited multiple times in several jurisdictions with more than 60,000 Medicare claims paid to date with zero refunds or deficiencies.
Code sharing is not new to ophthalmology. A notable example is the CMS presbyopia ruling, which allows for the billing for both cataract surgery (using CPT 66984 or CPT 66982) and the implantation of presbyopia-correcting IOLs. While it is similar, OBS code-sharing is somewhat more complex because the codes that are used vary depending on the jurisdiction in which the surgery is performed. The Code-Set Billing approach is a tailored combination of primary and secondary codes for each case. This customization ensures that billing accurately represents the services provided and aligns with local MAC policies.
On average, OBS surgeons receive reimbursement equivalent to the local ASC Geographic Practice Cost Index (GPCI). The GPCI is the index used to adjust Medicare reimbursements based on the relative costs of providing medical services in different geographic areas. This index takes into account variations in the costs of practice expenses, such as rent, salaries and malpractice insurance, which can vary significantly across different regions.
CMS, as well as many private insurers, recognize OBS as safe and cost-effective. The safety of OBS lens surgery is supported in the literature.2 Anecdotally, the rate of complications in our practice — although already rare — improved in OBS. We attribute this safety to having calmer patients, which results in less movement during surgery. What’s more, the vast majority of OBS cases require only mild oral sedation, which negates the need for an anesthesiologist or CRNA, if the surgeon chooses.
TRANSITIONING TO REIMBURSABLE MEDICINE
Historically, ClearSight has been an all-cash practice. However, my faith in iOR’s Code-Set Billing system is reflected in the fact that we recently added commercial insurance and will be expanding to Medicare cases later this year. This transition will enable us to serve a broader patient base while maintaining the high standards and personalized care that have defined our practice for three decades. While I am confident that the current OBS coding and billing process ensures adequate reimbursement, I am also mindful that CMS will likely standardize OBS reimbursement in the foreseeable future. In the 2023 final rule, CMS stated that it will continue to evaluate procedures in the non-facility setting (ie, OBS) and consider establishing non-facility codes in the future. CMS later requested more safety data on Medicare cases and OBS accreditation standards from iOR Partners and is currently considering the valuation of the current cataract and glaucoma codes for 2025.
While I do not think OBS will replace ASCs, I believe that the percentage of surgery done in an OBS will continue to increase. There is no way to accommodate the substantial anticipated demand for cataract surgery in the coming years without OBS. CMS and private insurers are aware of the key role that OBS plays in the growing demand for cataract surgery as a safe and cost-effective solution. This knowledge is integral to iOR’s ability to negotiate lucrative local jurisdiction reimbursement fees and will be critical to the eventual establishment of national OBS CPT codes. OM
References
1. Ianchulev T, Litoff D, Ellinger D, Stiverson K, Packer M. Office-Based Cataract Surgery: Population Health Outcomes Study of More than 21 000 Cases in the United States. Ophthalmology. 2016;123:723-728.
2. Kugler L J , Kapeles MJ, Durrie DS. Safety of office-based lens surgery: U.S. multicenter study. J Cataract Refract Surg. 2023;49:907-911.
