Optometry Coding & Billing Alert

Published on Tue Jan 22, 2008 PDF

Not all bad news: Payment for eye exams and E/Ms should rise -- slightly.

If your practice performs ophthalmic ultrasound regularly, get ready for a nearly 10 percent reimbursement reduction in 2009, resulting in almost $10 less pay for each scan.

That's one thing experts discovered when the Centers for Medicare & Medicaid Services released its final version of next year's Physician Fee Schedule. A lower conversion factor, combined with a reduction of the relative value units (RVUs) assigned to the technical component (TC) of certain diagnostic imaging procedures, will result in a national average reimbursement of only $96.30 (without geographical adjustments) for 76511 (Ophthalmic ultrasound, diagnostic; quantitative A-scan only)-- a 10.34 percent drop from 2008's $107.41.

Good news: But if you only perform the professional component of the ophthalmic ultrasound, you may see a small increase. The RVUs assigned to 76511-26 (Professional component) are rising from 1.33 to 1.34 in 2009 -- and although the conversion factor is slipping from 38.0870 to 36.0666, in 2009, CMS will no longer apply a budget neutrality adjuster (BNA) to a procedure's work RVUs. Result: A 76511-26 claim should bring in $48.33 in 2009, compared with $46.47 in 2008.

"There is a 6.5-percent, five-year practice expense reduction that has been in the works for the past five years, so without the 1.1 percent increase, we would be seeing a 6.5 percent overall decrease in reimbursement," says Barbara J. Cobuzzi, MBA, CPC-OTO, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions. "Instead, we are now seeing a 5.4 percent decrease."

Bad news: The loss in payment for the technical component of 76511 will more than offset the gain in the professional component. In 2009, 76511-TC only has 1.33 RVUs, compared with 1.60 in 2008. This brings the national payment for76511-TC down to $47.97 from last year's $60.94. Add $47.97 to the $48.33 payment for 76511-26 to arrive at the new global fee: $96.30.

Background: "The current five-year review [of Medicare payments] focuses only on the physician work component of specific procedures," explains Maggie M. Mac, CMM, CPC, CPC-E/M, ICCE, consulting manager for Pershing, Yoakley, and Associates in Clearwater, Fla. "However, future reviews will include the practice expense (technical component) when the resource-based values are established in the Medicare Fee Schedule. In other words, there are no work RVUs associated with the technical component of a procedure."

The ongoing reduction in TC payments will also affect your reimbursements for other ultrasounds:

• 76510 (Ophthalmic ultrasound, diagnostic; B-scan and quantitative A-scan performed during the same patient encounter) -- $147.15 in 2009 ($5.58 reduction from 2008)

• 76512 (... B-scan [with or without superimposed non-quantitative A-scan]) -- $90.53 in 2009 ($10.02 reduction)

• 76516 (Ophthalmic biometry by ultrasound echography; A-scan) -- $66.72 in 2009 ($4.50 reduction)

• 76519 (... with intraocular lens power calculation) -- $71.41 in 2009 ($4.00 reduction).

As with 76511, for each of these codes a small boost in the professional component RVUs is offset by a larger decrease in the technical component RVUs.

Bonus: Your payment for 76514 (... corneal pachymetry, unilateral or bilateral [determination of corneal thickness]) should rise slightly, from $12.19 in 2008 to $12.62 in 2009.

While the RVUs for several procedures slip down, payment for most E/M codes, 99201-99215 (Office or other outpatient visit ...), creep up slightly. Your reimbursement for the most commonly reported code increased; whereas you currently collect $59.80 for 99213 (not including geographic adjustment), you'll receive $61.31 for this service in 2009. And payments for 99214 will rise from the current amount of $89.89 to $92.33 next year.

The reimbursement for the eye exam codes also inches up. Expect $67.08 for an intermediate new-patient visit (92002, Ophthalmological services ... intermediate, new patient). For a comprehensive new-patient visit, 92004 (... comprehensive, new patient, 1 or more visits), you should see about $126.23. Anticipate $70.69 for an intermediate established-patient visit (92012, Ophthalmological services ... intermediate, established patient) and $103.15 for a comprehensive established-patient visit (92014,... comprehensive, established patient, 1 or more visits).

All of the 2009 amounts are a small increase (less than $2.00) from the 2008 amounts.

Download a copy of the Fee Schedule Relative Value File at www.cms.hhs.gov/PhysicianFeeSched