Every year, between October 1st and January 1st, several important events occur that affect billing, coding, and reimbursement for services for the coming year. On October 1st, the new International classification of diseases (ICD-10) codes go into effect.
Then on November 1st, the Centers for Medicare and Medicaid Services (CMS) issues its “Final Rule," which influences reimbursements, among many other processes, affecting services provided for Medicare patients.
Lastly, on January 1st, the updated current procedural terminology (CPT) codes and guidelines for their use for that year take effect. This article will review some of these updates and how they affect eyecare professionals (ECPs).
ICD-10 code changes
On October 1st, 2022, a significant number of updates went into effect. There are 1468 new codes, 251 deleted codes, and 35 revised codes. Here are some examples of ICD-10 code changes that ECPs should make note of.
Codes related to non-compliance
We all have patients who, for various reasons, are non-compliant with the care recommendations we discuss with them. Now, in addition to documenting the non-compliance, there are several codes in the Z91.1- code section which may be used to relay that information to insurers.
Essentially, the Z91.1- code section update is a means to explain why more frequent visits are required to deal with patient non-compliance.1
These codes may be important as insurers continue to move towards “value-based care,” which will reward those practitioners who are deemed to be providing more efficient care for various diseases.
Codes related to systemic conditions
There are also several new diagnosis codes for dementia (F01.-, F02.-, and F03.-) and traumatic brain injuries (S06.-).1 ECPs should note that when using the F02.- code series, you are required to define the underlying physiological condition potentially causing dementia and designate it as the primary code for billing purposes.
For diabetic patients, there is a new code (Z79.85) for long-term use of injectable non-insulin anti-diabetic drugs, such as Trulicity, Victoza, and Byetta, to name a few.1
Codes related to social determinants of health
Finally, there are several new codes in the social determinants of health (SDoH) group (Z55 - Z65), which are important to use when documenting when a patient’s social barriers, such as houselessness or a lack of transportation, may affect their care.
When billing an SDoH code, list the diagnosis code first and then the SDoH code second.1
In addition to documenting this information in the chief complaint and assessment or plan of the patient record, using one of these codes elevates the risk category for medical decision-making (MDM). Increasing the risk category for MDM, in turn, changes the level of the evaluation and management (E/M) visit to a moderate one. This may result in a higher reimbursement code when billed to the insurer.
CPT code changes
For 2023, there are 225 new CPT codes, 75 deleted codes, and 93 revised codes. When the major changes for the E/M codes went into effect in 2021, it required a “medically appropriate history and examination” (including a review of systems).
Additionally, these changes allowed code selection based upon MDM or time, which were only applied to outpatient patient office visits. In 2023, those changes now apply to inpatient care provided in hospitals, nursing homes, and assisted living facilities.2
The only new CPT code in the General Ophthalmology section is 92066, which is for orthoptic training done “under the supervision of a physician.”2
2023 CMS Final Rule
The Final Rule covers many different areas with respect to reimbursement for patient services. Every year the CMS assigns different services a value based on the number of relative value units (RVU) given to that service. The RVUs may be left the same, increased, or decreased. The dollar value of a service is determined by the CMS “conversion factor” per RVU. The total fee may vary for different areas of the country based on several different factors.
The 2023 conversion factor is $33.06, down from $34.61 in 2022, which is a 4.48% decrease. In addition to this decrease, there are two possible additional 1% sequestration decreases, plus a 4% pay-as-you-go (PAYGO) cut for 2023, which will occur unless Congress revises them.
The CMS has also reduced the base Part B premium to $164.90 and increased the Part B deductible to $226 for 2023. Additionally, the CMS has allowed telehealth services, which were enacted during the beginning of the COVID-19 public health emergency, to be extended through 2023 as the CMS continues to gather data on their use.3
In conclusion
With these significant changes happening every year, it is critical that practices invest in purchasing new CPT, ICD-10, and healthcare common procedure coding system (HCPCS) code books. Also, it is vital to inform the doctors and billing and coding staff annually of changes to ensure that practices are utilizing the codes accurately. Appropriate coding results in reducing the number of denied claims and increasing practice income at a time when all third-party payer fees are stagnant.
