Academy Outraged Over CMS Decision to Target
Key High-Volume Ophthalmology Codes for Five-Year Review

March 16, 2005

Washington—The American Academy of Ophthalmology is outraged by a decision by the Centers for Medicare and Medicaid Services (CMS) to target key high-volume ophthalmology codes for the upcoming Five-Year Review of Work Values. The potential impact of this decision on ophthalmology payments is enormous. Some of the targeted codes are:

• YAG capsulotomy
• Cataract with IOL
• Vitrectomy with epiretinal membrane stripping
• Photodynamic therapy
• Laser PRP
• Fundus photography
• Flourescein angiography
• Visual fields

“The list of codes CMS has decided to review appears arbitrary,” said Michael Repka, MD, Academy secretary for federal affairs. “With all the codes that have never been included in a Five-Year Review, we question why CMS targeted some ophthalmology codes that have already been reviewed through this process. No reason is given for these decisions. CMS just appears to have targeted high-volume codes. All of organized medicine is upset by CMS’s lack of rigor.”

There is cause for alarm not just for the codes identified, but for all ophthalmology codes.
“If the work value and time needed to provide cataract surgery are cut, it will negatively impact all other ophthalmic codes because of its effect on the practice expense methodology,” Dr. Repka said.

A 1990 law requires CMS to comprehensively review all physician relative work values at least every five years and make any needed adjustments. The review is important to all of medicine because Physician Work Relative Value Units (WRVUS) constitute 53 percent of any code’s payment.

In a Five-Year Review, CMS creates a list of codes it believes are overvalued or undervalued. It also seeks input from medical specialties in identifying codes. The list is then submitted to the AMA/Specialty RVS Update Committee (RUC), a physician panel that weighs the relative value of physician work involved in these procedures. For this review, CMS has targeted 14 ophthalmology codes as overvalued. The list also includes 15 undervalued codes submitted by the Academy, bringing the total number of ophthalmology codes up for review to 29. The Academy’s Health Policy Committee, with input from ophthalmic specialty societies, put the undervalued list together following a year of research.

The Academy will fight for all 29 ophthalmic codes before the RUC. Surveys on these codes will be sent to selected Academy Members in May. The data will be used to support the argument for increasing and/or maintaining the value of these codes. A complete list of ophthalmology codes up for review (77K)  is posted on the Academy’s Web site.

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.

The Academy’s track record before the RUC is impressive. Represented by Dr. Repka, Trexler Topping, MD, Greg Kwasny, MD, and Stephen Kamenetzky, MD, (all of whom volunteer their time), ophthalmology has lost only one vote on a new CPT code before the RUC in the last 12 years.

“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),” Dr. Repka said. “The Academy will make sure ophthalmology’s voice is heard in this critical review.”

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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: Governmental Affairs, 202.737.6662, or media@aao.org