November’s Academy meeting marked the 40th anniversary of my service as the Washington, D.C., counsel for OOSS. I am grateful to the pioneers and innovators who initiated a revolution in health care delivery—the provision of surgical care in the ophthalmic ambulatory surgical center (OASC), a patient-friendly, accessible, and reduced-cost surgical environment. I am grateful that the OOSS leadership over the years has encouraged me to think outside the box and aggressively pursue legislative and regulatory outcomes that seemed unachievable. I want to thank OOSS—its leadership, staff, and most importantly, you, our members—for providing me with an incredible career.
This article is not my swan song: I may be 40 years older than I was in 1983, but I’m nowhere near retirement. OOSS had a great year in 2023 and it is worth highlighting our successes, as well as the challenges we face in 2024.
CMS Increases and Updates
For this year, the Centers for Medicare and Medicaid Services (CMS) increased ASC payment rates by 3.1% on average. This represents the largest annual increase for ophthalmic surgery facility fees since the advent of the ASC program. Moreover, 2024 marks the 25th consecutive year-to-year increase in our Medicare facility fees.
Thanks in part to OOSS lobbying, for the period from 2019 through 2023 CMS agreed to update ASC payment rates by the Hospital Market Basket, rather than the lower Consumer Price Index-Urban. Under this policy, ASCs have received the same increase as hospitals, subject to certain adjustments. The policy was supposed to come up for review in the 2024 rulemaking period. However, because of data problems associated with the pandemic, the agency has extended the application of the Hospital Market Basket to ASCs for 2024 and 2025. OOSS will continue to strenuously recommend that CMS permanently maintain the Hospital Market Basket rate in computing the annual ASC payment update.
The agency also established a new sixth level in the Intraocular Procedures APC family base, and reassigned CPT codes 66989 and 66991 to a new APC, 5493. Medicare will pay $4,985 for these MIGS services.
ASC Quality Reporting
Regrettably—and over the objections of the ASC and ophthalmology communities—CMS has not formally repealed the misguided and administratively burdensome quality measure that requires facilities to report on patient visual function 90 days after cataract surgery. However, this measure will remain voluntary for now. OOSS will continue to lobby for the withdrawal of this measure
For the past several years, OOSS and the ASC and ophthalmology communities have been engaged in the process of developing and proposing new and appropriate quality reporting measures for ophthalmic ASCs. The agency adopted in 2019 a new ophthalmic quality measure, ASC 14: Unplanned Anterior Vitrectomy, which assesses the percentage of cataract surgery patients who have the procedure in an ASC. We will continue to recommend implementation of an ASC quality measure for toxic anterior segment syndrome (TASS).
Payment for New Technology IOLs
ASCs that implant lenses that have secured NTIOL status receive an additional $50 in facility reimbursement. CMS reports that there were no applications submitted by ophthalmics manufacturers requesting NTIOL status for lenses for the 2024 ASC payment rate rulemaking. As an incentive for innovation in monofocal IOL technology, OOSS, AAO, ASCRS, and the IOL manufacturers are recommending that the $50 payment for NTIOL be increased to $92 to account for inflation.
Office-Based Cataract Surgery
OOSS has absolutely and unequivocally opposed payment for office-based cataract surgery since CMS first considered implementing such a program in 2015. Our view is that facility payment should not be provided to offices until such time as they meet patient health and safety standards comparable to those required in ASCs. With other ophthalmology and ASC organizations, OOSS has repeatedly raised our patient health and safety concerns with federal health policy makers. OOSS conducted a comprehensive survey with input from hundreds of ophthalmic ASCs regarding the comorbidities associated with cataract patients, the results of which highlighted the need for rigorous patient health and safety standards, such as anesthesia, nursing care, emergency capabilities, and hospital transfer arrangements. Such mandates rarely apply in the unregulated office surgical suite.
The issue will be considered by CMS as part of the RUC review commencing in 2025, which means that, at the very earliest, payments for OBS could commence in 2027. This said, I do not believe that CMS will grant Part B
facility reimbursement to office cataract centers until: peer-reviewed clinical literature supports the safety and efficacy of OBS; the major ophthalmology organizations support payment for OBS; and appropriate standards for patient health and safety are established by CMS, state regulators, and/or private accreditation entities.
In the meantime, I urge caution in evaluating the financial model of commercial enterprises marketing office based surgical suites. The only appropriate reimbursement for Medicare Part B cataract in an OBS is the IOL. Reimbursement for anesthesia by the surgeon, an ABN, and other various codes are not allowed. There is no facility payment for cataract surgery in an OBS.
Final Thoughts
Despite our successes on the legislative and regulatory fronts, we face innumerable challenges. I urge you to continue to support OOSS during 2024 and to remain active in our grassroots lobbying initiatives. In deciding whether to engage, please ask yourself these questions: In the absence of OOSS’s work over these past four decades, could surgeons still own and refer their patients to ASCs? Would our facility payments have increased by 350%, or would they have declined like professional fees? Would we be able to perform and be paid for virtually every ophthalmic procedure in the ASC? Would Medicare ASC facility regulations be even more burdensome, threatening the very viability of the ophthalmic ASC? OASC
