January 21, 2005

Washington—As part of the American Academy of Ophthalmology’s formal comments on the 2005 Medicare Physician Fee Schedule final rule earlier this month, the Academy identified 15 ophthalmic CPT codes whose physician work was deemed undervalued.

This marked the launch of ophthalmology’s effort in the Five Year Review of Work Values. The Centers for Medicare and Medicaid Services (CMS) and organized medicine will spend the next two years looking at the physician work values during the Congressionally mandated Five Year Review. Physician Work Relative Value Units (WRVUS) constitute 53 percent of any code’s payment. 

The proactive move to identify the 15 undervalued codes is based on a year-long review by the Academy’s Health Policy Committee, with input from ophthalmic specialty societies. The Academy will also work with specialties to defend any ophthalmic code whose work is deemed to be overvalued because technology has made it easier or faster to perform.

A 1990 law requires CMS to comprehensively review all physician relative work values at least every five years and make any needed adjustments. In this effort, CMS refers all codes thought to be over or undervalued to the AMA/Specialty RVS Update Committee (RUC), chaired by William L. Rich III, MD, who also serves as the Academy’s medical director of health policy. Over the next nine months, the RUC will review the codes and make recommendations on new values to CMS in September. CMS will then publish a proposed rule in the spring of 2006 for comment. Final values will be published in November 2006, with implementation in January 2007. CMS typically accepts 96 percent  of RUC recommendations. In February, CMS will publish the list of all codes deemed to be undervalued by physicians or overvalued by payers.

“Each five-year review presents an unprecedented opportunity to improve the accuracy of the physician work component of the Resource-Based Relative Value Scale (RBRVS, the methodology used for the payment of all physicians' services),” said Michael Repka, MD, Academy secretary for federal affairs. “The Academy will make sure ophthalmology’s voice is heard in this critical review.”

As part of the five-year review, the Academy will call on selected members to complete surveys. The Academy will use data obtained from the surveys to support its argument for increasing the value of these codes before the RUC.

In other comments related to the 2005 Physician Fee Schedule, the Academy asked CMS to make adjustments to the bilateral indicators for several of our procedure codes and requested a change in the global period for peripheral iridectomy.

The Academy has also been outspoken regarding CMS’s plan to create model drug guidelines. As part of its effort to implement the Medicare prescription drug benefit that passed in 2003, CMS called on the United States Pharmacopeia (USP) to draft model guidelines that could be used to determine Medicare patients’ access to drugs.

The Academy felt the initial guidelines, published by USP in August 2004, failed to provide a comprehensive listing of all ophthalmic drugs – a deficiency that could limit patient accessibility to drugs necessary for successful treatment

“The Academy felt strongly that the proposed guidelines for ophthalmic agents were overly broad and would allow plans to omit many valuable drugs,” Dr. Rich said. “For example there were only three classes of ophthalmic agents: antiglaucoma medications, mydriatics/cylcoplegics, and other.”

The Academy quickly notified ophthalmic specialties and worked with the ophthalmic industry to comment on the proposed guidelines. With the American Glaucoma Society, the Academy submitted detailed comments suggesting specific revisions to the draft model guidelines. 

As a result, the USP’s final guidelines, published on Dec. 31, 2004, included many of the Academy’s recommendations. 

“There are now appropriate classes of drugs to ensure that our patients and physicians will have access to all classes of our clinically useful drugs,” Dr. Rich said. “We’re very pleased. We feel confident we’ve done our job.”

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The American Academy of Ophthalmology is the voice for ophthalmologists and their patients in Washington, D.C., and is the world's largest organization of eye physicians and surgeons, with more than 27,000 members.

Reporter Contact: Media Relations, 415-561-8534, or media@aao.org