Lobbyists win code-review battles; physicians still face cuts in 2007

Codes for vitrectomy and other common retina procedures are under review because they no longer describe today's procedures.

Despite some victories in preserving and improving 11 Medicare payment codes, ophthalmologists will see some significant changes in 2007 unless Congress intervenes to stop across-the-board cuts.

The payment code analysis, mandated by the Centers for Medicare and Medicaid Services (CMS) and called the Five-Year Review, determines whether physicians are appropriately compensated for their work. Specialty medical societies were asked to offer what they thought were misvalued procedures, and CMS devised its own list of codes to be reviewed.

After much lobbying by the American Academy of Ophthalmology (AAO), Amer- ican Society of Cataract and Refractive Surgery (ASCRS), and other medical societies, CMS has agreed to make more moderate changes to the codes used by ophthalmologists. The revised codes, called Work Relative Value Units (RVUs), will be effective Jan. 1.

The AAO surveyed and presented data for 25 codes that could be adjusted, and won increases for 11 codes, according to Cohen. Values for another 11 codes challenged by CMS were maintained at current levels, and minor decreases were ordered for the physician work value portion of three codes: cataract with IOL (66984), photodynamic therapy for choroidal neovascularization (67221), and correction of trichiasis epilation by forceps (67820).

Meanwhile, nearly all codes relating to office visits-evaluation and management-saw significant improvements, including increases by as much as 37%.

"We succeeded on every code we proposed as undervalued," Cohen said. "We have a good track record."

The team of physicians representing ophthalmology was particularly challenged in defending the code value for performing cataract surgery with an IOL, because survey data showed the procedure now takes less time than it did 5 years ago.

In its alert, ASCRS noted that the intra-service physician time required for cataract surgery has decreased from 50 to 30 minutes. However, the group said the decrease in time spent reflects a decrease of only low-intensity work (suturing). The code was considered particularly critical given the volume of these cases for most ophthalmologists.

Ophthalmology Times' telephone call to ASCRS' Nancey McCann was not returned by press time.

Stephen A. Kamenetsky, MD, AAO's official presenter at the Relative Value Update Committee (RUC), stressed that cataract surgery deserves higher payment because the technical difficulty of the procedure-through a small incision with a foldable or injectable lens and a self-sealing corneal incision-has increased even though the time required to perform it has decreased.

"The time that was eliminated was related to the lower-intensity work of creation of a large wound and its subsequent closure, and was more than compensated for by the increase in skill required for the newer cataract operation," he said, adding that the RUC accepted that reasoning. "This confirmed the AAO position that time alone is a poor measure of physician work and that using it as a proxy for work to determine payment will stifle innovation for all specialties."

Advocacy groups were also concerned about key retina codes that they feared would be slashed under the review. However, we were successful in getting decisions about those codes deferred for at least a year until CMS' Current Procedural Terminology committee can evaluate them, Cohen said.

Dr. Kamenetsky said these codes-for vitrectomy and other common retina procedures-are under review because they no longer describe today's procedures. The AAO will submit revised and updated codes later this year, he said.

"We believe that the values obtained will accurately reflect the physician work for these codes and will result in fair reimbursement for retinal specialists," he said.

In spite of these positive results, Congress and CMS continue to try to rein in spending. For example, even though ophthalmology won work value increases on many codes, under the Omnibus Budget Reconciliation Act of 1989, the payment for some codes will be reduced to preserve "budget neutrality."

"Unless Congress increases the amount of money in the pool, any increases the RUC recommends has to be paid for within the pool," Cohen said.