Every year, usually in July, CMS issues a “Proposed Rule” which outlines changes in the Medicare program for the following year. These changes cover a wide array of issues affecting the Medicare program and optometry. Some of the items addressed in the proposed rule are fees for service, adoption of new CPT codes, and changes in definitions for services, such as telehealth medicine.
After a public comment period, CMS then releases a Final Rule in early November; the policies in the Final Rule go into effect on January 1 every year.
One of the most anticipated parts of the proposed rule is how fees for provider services will be affected as dictated by the Physician Fee Schedule (PFS). The PFS for various services can be changed in a couple of different ways. Each service has a certain number of Relative Value Units (RVU) assigned to it based upon several factors. CMS then determines a Conversion Factor (CF), which assigns a dollar value to each unit of RVU.
Fees may be increased or decreased by changes in either the RVUs assigned to a service or the CF value. Congress usually finds ways to change the CF each year. For example, the current CF is $34.60 per RVU, a 0.89% decrease from 2021, had the potential to decrease by a much higher factor initially.
However, barring Congressional intervention, the CF is still subject to two additional 1% decreases in April and July of this year. The CF may also vary between different areas of the country, based upon certain cost of living factors.
New updates for tele-optometry
Telehealth services have been given an extension of the relaxed rules enacted during the Covid Public Health Emergency period. CMS, because of both doctor and patient positive feedback, has decided to extend the current rules until 12/31/23, in order to study the continued health benefits of telehealth.
However, along with that extension comes increased scrutiny for abuse of these services by unscrupulous providers by the Office of Inspector General (OIG). OIG has already convicted a few providers under the False Claims Act for filing false telehealth claims.
To better monitor some aspects of telehealth calls, CMS has adopted some new modifiers and place of service codes:
- Modifier 93 (new) - used for synchronous audio only telehealth visits. These are usually billed using the 99441-99443 CPT codes.
- Modifier 95 - used for synchronous audio/visual telehealth calls. These are usually billed using the 992xx E/M codes used based upon time.
- Place of Service 02 (new) - used when the patient IS NOT at their house during the call.
- Place of Service 10 (new) - used when the patient is at their house during the call.
New CPT codes for 2022 that may affect optometry
CMS also adopts changes to the CPT coding system on January 1 of every year. CPT is a copyrighted coding system owned and managed by the American Medical Association with input from many interested parties affecting both adoption of new codes, deletion of some codes and some revisions in descriptions for some codes.
For 2022, there are 249 new CPT codes, 93 revised CPT codes, and 63 CPT deleted codes.
A few of the new codes which may affect optometry are as follows:
- 66989 - complex cataract surgery (abbreviated description)
- 66981 - routine cataract surgery with MIGS (abbreviated description)
- 0671T - MIGS without concomitant cataract surgery. (There are currently no MIGS devices approved for this)
- 68841 - insertion of drug eluting implant into lacrimal canaliculus (abbreviated definition)
Updates to the Merit-Based Incentive Payment System (MIPS)
Another area addressed in the Final Rule is proposed changes for the Merit Based Incentive Payment System (MIPS) which has been in place for several years now. CMS has been instituting changes for the past several years to transition to a standard fee for service program (where providers are paid based upon the number of services they perform) to a system based upon quality of care, treatment outcomes, and cost efficient care.
Over the past few years, those providers who participated in the MIPS program, by reporting certain healthcare measures, were able to avoid cuts in their fees and possibly obtain some fee increases. Currently, one of the most important MIPS measures is reporting the annual dilated retinal exam, with or without retinopathy, for patients ages 18 to 75.
The next step in this reimbursement shift is supposed to occur in 2023 when the CMS begins the MIPS value Pathways (MVPs) program. Stay tuned for more information as this program evolves.
What optometrists should know about the 2022 CMS final rule updates
What can you do, in light of all of these changes, in a period of significant inflation and stagnant fees, to maintain and increase your practice income?
1) Spend the time and money, every year to educate yourself and the appropriate staff members on the changes in billing and coding. Ensuring insurance claims are filed properly is a key way to retain a consistent level of practice income. If more than 5% of your claims are being denied due to filing errors, you need to find the problem and correct it quickly.
2) Transition towards your practice doing more medical eyecare versus “routine” care, usually covered by vision plans. Invest the time to learn how to incorporate more medical eyecare into your practice. In light of the cost of business today, you can not afford to continue to accept the 1990s exam fees the vision plans pay. As these plans continue to aggressively solicit your patients to purchase their optical goods through vision plans at their own brick and mortar locations or websites, you can no longer count on “making up” for the low exam fees through optical sales.
3) Apply to be credentialed for the medical provider panel of the Medicare Advantage (MA) plans, which are quickly moving patients from standard Medicare to these HMO-like plans. Do not allow yourself to be relegated to only being able to do “routine” exams through the vision plans, which are quickly affiliating with these MA plans. Very few Medicare patients do not have some type of pathology.
4) Bring new technology into your office which allows you to provide more medical services. However, do not rely wholly on the financial return projections salespeople provide when making your purchase decisions. There are several Facebook and other online groups with hundreds of optometrists willing to exchange ideas and information.
Darwin’s principle of “survival of the fittest” is very applicable to optometry. Those who are able to adapt quickly to major shifts in practice scope and understand and incorporate changes, such as those covered every year in CMS’s Final Rule, will survive.
