Optometry Coding & Billing Alert

Published on Mon Jun 15, 2009 PDF

Plus: 21.5 percent cut looms for your services.

Heavy pay cuts for your physician's services could be on the horizon, according to the proposed Medicare Physician Fee Schedule, printed in the July 13 Federal Register.

CMS is projecting a record 21.5 percent rate cut, and proposes halting payment for consult codes (99241-99245) in 2010. Instead of reporting consult codes, you'd report new or established patient office visit E/M codes (99201-99215) for these services, and CMS would increase payments for the existing E/M codes.

To determine the impact of this change, you'd have to compare the reimbursement from the new fee schedule office visit fees versus the current office consult fees, as well as the new hospital visit E/M charges versus the current hospital consult fees, says Quinten A. Buechner, MS, MDiv, CPC, ACS-FP/GI/PEDS, PCS, CCP, CMSCS, president of ProActive Consultants in Cumberland, Wis.

Using this year's figures, you'd lose between $16 and $45 for office consults that would now be coded as newpatient  visits, and you'd lose $30 to $100 for established office consults coded as E/Ms, Buechner says. A rough calculation shows that the additional E/M payments (proposed at 6 to 8 percent) may not cover the loss of consult money.

Even if an optometrist acts more often as a referrer to the specialist (and therefore not as affected by the pay cut as the specialist himself), experts warn that the pay cut may hamper communications between the specialist and your optometrist. Currently, a specialist must communicate his findings back to the referring optometrist to fulfill the consult code requirements -- an arrangement that may end if CPT eliminates the consult codes.

Whether the pay cuts will actually become final is anyone's guess. "Since far less draconian cuts have been  reversed by Congress over the past seven years, and since the current plan in Congress and in the Obama administration is to finalize a healthcare reform package by November, I expect that this issue will be addressed before the draft regulation takes effect," says David C. Harlow, Esq., of The Harlow Group in Newton, Mass.

Some expressed concerns, however, that CMS would not address the payment issues in a structural manner. "That would require a wholesale change in reimbursement methodologies, to a value-based purchasing approach that does not rely on the current piecework system," Harlow said. "More likely is the imposition of a new stopgap measure (e.g., by removing physician-administered drugs from the basket of costs subject to the sustainable growth rate) that does not address the underlying issues."