Multiple Procedure Payment Reductions Now Applies to Ophthalmologic Procedures

by Nancy Clark, CPC, CPC-I

Effective January 2013, reduced payment has been made for specific ophthalmologic diagnostic codes. These codes are identified in the Medicare Physician Fee Schedule with the new Multiple Procedure value of “7.”

Diagnostic ophthalmology services subject to MPPR include (code listed with short descriptor):

76510 Ophth us b & quant a

76511 Ophth us quant a only

76512 Ophth us b w/non-quant a

76513 Echo exam of eye water bath

76514 Echo exam of eye thickness

76516 Echo exam of eye

76519 Echo exam of eye

92025 Corneal topography

92060 Special eye evaluation

92081 Visual field examination(s)

92082 Visual field examination(s)

92083 Visual field examination(s)

92132 Cmptr ophth dx img ant segmt

92133 Cmptr ophth img optic nerve

92134 Cptr ophth dx img post segmt

92136 Ophthalmic biometry

92228 Remote retinal imaging mgmt

92235 Eye exam with photos

92240 ICG angiography

92250 Eye exam with photos

92265 Eye muscle evaluation

92270 Electro-oculography

92275 Electroretinography

92283 Color vision examination

92284 Dark adaptation eye exam

92285 Eye photography

92286 Internal eye photography

Reimbursement for the professional portion of the service reflects the full fee schedule amount; however, the technical portion of the service is reduced by 20 percent for each subsequent procedure performed on the same day by the same physician or group.

Medicare Administrative Contractors (MACs) are instructed to use modifier 51 on the Explanation of Benefits (EOB) to identify reduced TC and global services.

Payment Example

The chart below references CPT® code 92235 Flourescein angiography (includes multiframe imaging) with interpretation and report and 92250 Fundus photography with interpretation and report performed on the same day. Each procedure has both a professional component (PC) and a technical component (TC), and each component is associated with a portion of the fee schedule.

CPT® Code 92235 CPT® Code 92250 Total 2012 Allowed Amount Total 2013 Allowed Amount Payment Calculation
PC $46.00 $23.00 $69.00 $69.00 No Reduction
TC $92.00 $53.00 $145.00 $134.40 $92.00 + (80% x $53.00)
Global $138.00 $76.00 $214.00 $203.40 $69.00 (PC) + $92.00 + (80% x $53.00)

In either 2012 or 2013, if the physician billed for only the PC of both procedures, reimbursement would be based on the allowed amount of $69.00 ($46.00 plus $23.00). If the physician billed for only the TC of the procedures in 2012, reimbursement was based on the allowed amount of $145.00 ($92.00 + $53.00).

In 2013, Medicare will decrease the second procedure’s technical component by 20 percent, yielding an allowed amount of $134.40 [$92.00 + (80% of $53.00)]. Total reimbursement for the physician who performs the global procedure (TC and PC) is reduced due to the TC reduction.

In this example, the same two procedures performed would have been allowed $214.00 in 2012 but only $203.40 in 2013. For frequently performed procedures, this loss will multiply. And remember: Unless medical necessity dictates performing the procedures on different dates, having the patient return at a later date to obtain full reimbursement on each procedure may be considered abuse.

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