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Weighing impact of procedures targeted for re-valuation


Despite a heightened atmosphere on the Relative Value Scale Update Committee due to Congressional mandates to reallocate funds from specialty codes, ophthalmologists have been spared from the significant financial impact affecting certain other specialties. However, a number of important ophthalmic codes have been placed under review, leading to decreases in payment for some procedures.

By Nancy Groves; Reviewed by John T. McAllister, MD, and Cherie McNett

The Relative Value Scale Update Committee (RUC)-the multispecialty committee that provides recommendations to the Centers for Medicare and Medicaid Services (CMS)-was designed to keep service valuation consistent with current medical practice. It is this committee that is at least partly responsible for the perception of many physicians that their payments are continually being lowered.

The system has worked reasonably well since its inception in 1991 but has been affected by two bills passed by Congress in 2014, according to John T. McAllister, MD, who is in private practice in Fairfax, VA.

One is the Protecting Access to Medicare Act (PAMA), which mandated reallocation of approximately $1 billion per year through 2020 by reducing misvalued specialty codes.

However, another piece of legislation, the Achieving a Better Life Experience Act (ABLE), shortened the period of Congressionally mandated code revaluation.

While the RUC continues to review potentially misvalued codes, the Congressional mandate expired at the end of 2017-although it may be revived at any time as part of Congressional budget maneuvering, according to Cherie McNett, director, health policy, American Academy of Ophthalmology.



The Review Process

The RUC consists of a volunteer group of 31 physicians as well as medical advisors from all major specialties and subspecialties. Over the course of its existence, more than 2,300 codes have been reviewed and $4.5 billion redistributed through a system of weighting within a framework of budget neutrality. More than three-fourths of all codes have been deleted, decreased, or reaffirmed, according to historical CMS data.

While ophthalmology has been impacted by this coding review process, compared with other specialties it has done relatively well and taken less of a hit in payments from the Medicare program. The net impact on ophthalmology since 2009 was 0%, while the hardest hit specialty was radiology, experiencing a 77% decline in payments.

“To put it in perspective, while we all continue to get squeezed, ophthalmology has been doing relatively well,” Dr. McAllister said. “The downside is that we’re sticking out a little bit like a sore thumb, so ophthalmology may have problems in the future.”



Under scrutiny

The prospect of significant impact from future code reviews is in part due to the Congressional actions of a few years ago. Under the 2014 mandates, “the mood of the RUC has become hypercompetitive,” Dr. McAllister said. “Pennies are pinched, minute details are scrutinized, every fraction of an RVU is held in suspicion. Each dollar that one specialty loses is a dollar that is added to the pot from which all the other specialties are reimbursed, so each of the voting specialties is incentivized to see the other specialties’ values decrease. Thus frequently when a code comes up for review, value is lost. It is not good to have your codes brought up for review in this climate. Because the grand majority of codes are specialist’s codes, primary care consistently gains value as specialists consistently lose value.”

“The trend has also become to add emphasis to time and to de-emphasize intensity, because it’s very difficult to compare the intensity of a C-section to that of a cataract surgery, but you can easily compare the times,” he continued. “This hurts us because we’re extremely efficient in ophthalmology. We do highly intense codes in a very short period.”

In order to protect themselves, ophthalmologists should respond to RUC Physician Work Surveys, which are the basis for the RUC’s recommendations to the CMS, Dr. McAllister said.

Knowing the power of these surveys, physicians may be tempted to exaggerate or underestimate when responding, but this is inadvisable.

“The RUC has easily pointed out when surveys are flawed or are weak, and it’s easy for them to throw out bad data,” he said. “Please be accurate and honest, but please respond.”


Codes can be brought up for review by several mechanisms. One is through the Relativity Assessment Work Group (RAW), formed by the RUC in 2006 to identify potentially misvalued codes and consider the value of new technology services.

A recent example of this involved bundled CPT services that are often billed together; in ophthalmology, this was applied to fluorescein angiography and ICG angiography, which are often billed on the same day and overlap in time, inputs, and value.

Unfortunately, a new combined code was created, extracting duplicate time, disallowing payment for camera film, and being designated as a typically-bilateral procedure, eliminating 50% of the value.

Codes associated with high-volume growth and high expenditures can also be a red flag. Cataract surgery has been flagged in the past for high expenditures and high volumes but also for intensity, or having high intra-service work per unit of time.

Scrutiny of postoperative visits has also affected ophthalmology, hitting glaucoma specialists particularly hard because of the significant amount of chair time after surgery. Because they typically require-and are reimbursed for-extra postoperative visits, the codes for trabeculectomy, retinal detachment repairs, amniotic membrane transplantation, and laser trabeculoplasty have all been reviewed because of their frequency of follow up.

Some ophthalmic codes are flagged for having a negative intensity metric as they are high intensity procedures performed over a short time.

To complicate matters, the CMS can respect RAW’s screens, make small adaptations-which may make the screen more stringent-or occasionally request their own screens, Dr. McAllister said. In a slight silver lining to the situation, CMS did not request any new screens in 2017.

The processing of reviewing potentially misvalued recently is open to the public, but those who wish to comment must provide extensive data to CMS before any action would be considered. 


John T. McAllister, MD

e: johntmcallister@gmail.com

This article was adapted from a presentation at the 2017 meeting of the American Academy of Ophthalmology. Dr. McAllister did not report any relevant financial disclosures.


Cherie McNett

p: 202/737-6662     e: cmcnett@aao.org

McNett is director of health policy with the American Academy of Ophthalmology.


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