On Jan. 1, 2011, the Centers for Medicare and Medicaid Services (CMS) implemented major changes in reimbursement for important vitreoretinal codes and began payment for some new imaging codes. These changes are the culmination of a several-year process that will have significant financial implications for all vitreoretinal practices. This article discusses the history and processes behind the new numbers and codes.
INTRAVITREAL INJECTION CODE
The biggest cut in payment for 2011 is for code 67028,
intravitreal injection of a pharmacologic agent (separate
procedure). Payment has been reduced from approximately
$200 to $125. This cut is the result of more than
2 years of review of this service. In 2007, at the request of
CMS and the Medicare Payment Advisory Commission
(MedPAC), the American Medical Association (AMA)
Specialty Society Relative Value Update Committee
(RUC) created a workgroup to evaluate potentially misvalued
codes on an ongoing basis. This was in response
to increasing criticism that the RUC has been too generous
to some specialties.1 The workgroup created screens
to identify codes that needed review. As of May 2010, the
RUC identified 853 services for review and has completed
review of 622 codes. The remaining codes are scheduled
for review over the next year. One of the first screens
used by the workgroup was high-volume Current
Procedural Terminology (CPT) codes with a 15% increase
in utilization since 2006. The underlying assumptions are
that if volume increases, there may be anomalous economic
incentives or that physicians have become more
efficient in the provision of the service. In a resourcebased
reimbursement system in which time is the primary
resource, efficiency means less time per procedure,
which means less payment. Not surprisingly, code 67028
was at the top of the list. Since 2000, utilization of 67028
in Medicare fee for service has increased from approximately
4,000 per year to a projected 1,000,000 in 2010.
The American Academy of Ophthalmology (AAO) presented
compelling scientific evidence that the increase in volume was attributable to the advances in retinal pharmacologic
therapy, and the RUC agreed that the code
should be removed from the review list. However, in the
proposed 2009 Medicare Physician Fee Schedule published
in July 2008, CMS demanded review of all codes
with utilization over 100,000 that had not been previously
reviewed by the RUC. Because code 67028 had not
been reviewed by the RUC, the RUC directed the AAO to
conduct a formal survey of code 67028 for presentation
and valuation at the October 2009 RUC meeting.
The prior valuation of code 67028 had a physician work relative value unit (RVU) of 2.52, which was based on times from the initial Resource-based Relative Value Scale (RBRVS) process in 1992. These times totaled 44 minutes, allocated as 14 minutes for pre-service time, 16 minutes for intra-service time and 14 minutes for post-service. The new survey of 118 retina specialists who were experienced in providing the service demonstrated a total mean time of 15 minutes, with 5 minutes each for the pre-, intra- and post-service times. The AAO presented a detailed argument about the value of 67028, which considered the intensity and complexity of the procedure and the relative value compared to other similar codes. The RUC rejected the AAO recommendation and assigned a work value of 1.44 RVU. The AAO strongly disagreed with this value, believing it did not reflect the intensity and complexity of an intravitreal injection. Therefore, the AAO appealed to the RUC's Administrative Committee on the basis of inconsistencies in the RUC process. The appeal was denied, and the AAO then appealed directly to CMS through a formal presentation. Julia Haller, MD, joined the AAO team at that CMS appeal. Unfortunately, this appeal was denied. The AAO continues to believe that the new valuation of 67028 is inconsistent with previous RUC policies and valuations and creates rank order anomalies with other ocular injection codes.
In the new value, the RUC assumed that the typical patient receiving an intravitreal injection will also receive an evaluation and management (E/M) service on the same day. This assumption was based on recent Medicare analysis of codes billed on the same day as 67028. This decision eliminates most pre-service and post-service time from the valuation of the procedure. Therefore, retina specialists may bill an E/M service on the same day as an intravitreal injection, assuming appropriate medical necessity and documentation.2 Other medically necessary diagnostic imaging and testing services also remain billable separately. The value for 2011 is an interim value, and the AAO, in conjunction with the American Society of Retina Specialists, is considering further appeal options.
POSTERIOR-SEGMENT IMAGING
The other major change involves codes for posterior segment
imaging. Code 92135 no longer exists, and it has been
replaced by two new codes, 92133 and 92134: Scanning
computerized ophthalmic diagnostic imaging, posterior
segment, with interpretation and report, unilateral or bilateral;
92133 optic nerve; 92134 retina. Code 92135 was identified
on the previously discussed screen for volume. The
utilization for 92135 in the Medicare fee for service database
increased from approximately 150,000 in 1999 to over
8,000,000 in 2008. Again, this growth was due to the development
of new and effective drugs for retinal disease as
well as improved technology. The AAO effectively argued
that the growth was appropriate, but the previous valuation
was based on use in glaucoma. It was apparent that
92135 was no longer an accurate descriptor of the service.
The RUC referred code 92135 back to the CPT Editorial
Panel, which determined that two new codes were needed
for posterior segment imaging to describe the different
work for glaucoma and retinal disease. The CPT Editorial
Panel also decided that these codes should be unilateral or
bilateral as with fundus photography, code 92250. Once
these new codes were developed, the RUC required the
AAO to survey both codes. Based on the survey results, the
RUC assigned and CMS accepted a work value of 0.5 RVU,
which is more than the previous unilateral code (92135)
value of 0.35, but obviously less than the bilateral value.
Keeping in mind that the key word in RBRVS is “relative,” a
chest X-ray has a work RVU of 0.18.
In 2011, there are two new codes for remote retinal imaging. These codes were developed at the request of industry with the support of the AAO through the CPT process. The first is code 92227: Remote imaging for detection of retinal disease (eg, retinopathy in a patient with diabetes) with analysis and report under physician supervision, unilateral or bilateral. This code has no physician work and is intended for use by nonphysician readers. The only payment is for practice expenses. The second code is 92228, remote imaging for monitoring and management of active retinal disease (eg, diabetic retinopathy) with physician review, interpretation and report, unilateral or bilateral. This code for physicians who perform remote imaging has a work RVU of 0.30. This code should not be used unless a physician performs the service for each patient. Physician supervision of nonphysician readers is not adequate for this code. The physician must interpret and write a report on each study.
DEVALUING PHYSICIAN SERVICES
The process of valuing physician services is under
intense scrutiny from both within and outside medicine.
In particular, the RUC process continues to be criticized.3
Many retina specialists are frustrated by the continuing
decline in reimbursement for our services. The current
RBRVS process is increasingly being driven by physician
time, while intensity and complexity are becoming less
important. For those who may wish there was a different
system, be careful what you ask for. The 2010 Patient
Protection and Affordable Care Act creates a potential
alternative to the RUC called the Independent Payment
Advisory Board (IPAB) which is charged with limiting
growth in Medicare expenditures. The IPAB will consist of
15 individuals nominated by the President and confirmed
by the Senate. In 2014, the IPAB will submit legislation to
Congress to reduce the per capita rate of growth in
Medicare expenditures if spending exceeds a target
growth rate, which is determined by the consumer price
indices. This legislation must be voted up or down without
input from Congress. Interestingly, the IPAB is precluded
from cutting hospital, hospice or clinical lab payments
until 2019. Also, IPAB cannot ration care, increase
taxes, or change benefits or copayments. If you are thinking
that does not leave much to cut except physician payments,
you are right. CMS estimates that the IPAB will
result in a $24 billion savings between 2014 and 2019, and
nearly all of that will come from physician payments.
George A. Williams, MD, is Chair of the Department of Ophthalmology at William Beaumont Hospital and Director at Beaumont Eye Institute in Royal Oak, MI. Dr. Williams is a Retina Today Editorial Board Member. He is also the delegate for the American Academy of Ophthalmology (AAO) to the Amercian Medical Association's Specialty Society Relative Value Scale Update Committee (RUC) and a member of the AAO's Health Policy Committee. Dr. Williams has no financial interest in the information contained in this article. He can be reached via e-mail at GWilliams@beaumont.edu.
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