In the 2007 Fee Schedule, CMS significantly increased payments to E&M codes for office visits, but not to the corresponding eye visit codes. It looks like CMS will rectify this for 2008. Here's how rational argument, backed by sound data prevailed.

Stephen A. Kamenetzky, MD, was sweating, physically and metaphorically, as he entered a conference room at the San Diego Omni Hotel on Feb. 4. He was there for a meeting of the AMA’s Relative Value Update Committee (RUC) and was carrying a heavy load—about $30,000 in annual billings for each U.S. ophthalmologist. That’s how much was at stake as he tried to convince the RUC to reconsider a decision made the previous year to delink the work relative value units (RVUs) for the four CPT eye office visit codes from the corresponding E&M codes, which are used by internists and others.

Earlier that day, the RUC had voted to reject Dr. Kamenetzky’s argument that the work RVUs for three eye office visit codes should be increased appreciably. (The Academy recommended that the fourth code, CPT 92002, should stay the same.) Now, he was taking a second, final run at the RUC, in a last-ditch, hurry-up offense. Dr. Kamenetzky may have had the Peyton Manning role in what amounted to a Super Bowl game, but the associate clinical professor of ophthalmology and visual science at Washington University in St. Louis had been backed by a team of Academy members and staffers who had put in an all-star effort to bring him to this point.

Before the day was out, Dr. Kamenetzky had convinced the RUC in three very close votes—one for each eye office visit code—that the Academy had proved its case.

This July, the CMS ratified the RUC’s recommendations and proposed increasing Medicare fees for the three eye codes in calendar year 2008, a decision that if finalized—which is very likely to happen—also will reverberate in the private carrier market.

Given the fact that most ophthalmologists get about 65 percent of their income from eye office visit codes (including the minor procedures and diagnostic testing that accompany such visits), that increase in work RVUs will yield significant extra payments for the profession—amounting to approximately $154 million annually from Medicare alone.

CMS DELINKS EYE CODES FROM E&M CODES

Until the 2007 Fee Schedule, work RVUs for the eye visit codes had increased in lockstep with the work RVUs for the corresponding E&M codes. This was because in 1995, the Health Care Financing Administration, now known as the CMS, had proclaimed that work RVUs for the two types of code were “permanently linked.”

And in 2005, as the RUC began to survey the work values for E&M codes as part of a five-year review of work RVUs, the Academy had no reason to suspect that this linkage might be sundered. The Academy decided not to resurvey the work RVUs of the four eye visit codes in the belief that the “permanent” linkage meant that surveys being done of the E&M codes would provide data for the eye visit codes as well.

However, a notion was taking hold within the RUC Five-Year Review Work Group that, by not resurveying the eye visit codes, ophthalmologists were not pulling their own weight. In March 2006, the RUC recommended to the CMS that work values for nine of 10 E&M codes receive up to 35 percent increases, but declined to give similar increases to the corresponding eye visit codes.

This RUC decision to delink the eye visit codes from the E&M codes was endorsed by the CMS in August 2006 when it published its proposed fee schedule changes for 2007.

THE ADVOCACY TEAM SPRINGS INTO ACTION

First, the Academy convinced the CMS that the RUC’s delinkage decision and the CMS’ acceptance of it were, at a minimum, at variance with the HCFA’s 1995 policy.

Office visits are increasingly complex—but how do you prove that? Michael X. Repka, MD, Academy secretary for Federal Affairs and professor of ophthalmology and pediatrics at Johns Hopkins University, said, “Just take the management of glaucoma. We have many more drugs that we can consider. Moreover, there are many more surgical techniques available that weren’t around five or 10 years ago. There is more diagnostic information to evaluate and consider from such diagnostic techniques as optic nerve head analysis.” The Academy’s leaders knew that if they were given a chance to survey ophthalmologists, they would find that office work for the eye visit codes had increased considerably since the last time work RVUs were adjusted, and probably in the same range as the work RVUs for the E&M codes.

Collecting the data. In October 2006, the Academy sent surveys to ophthalmologists around the country. Hopefully, the survey results would demonstrate that office visits had become more complicated and now involved additional work. This is when the tough, trench work took place.

The form for the RUC survey is pretty standard. The challenge, for the Academy or any other specialty medical society going through the RVU reevaluation process, is to convince enough members not just to fill out the surveys, but to do so thoughtfully and promptly.

Cathy Cohen, the Academy’s vice president of Governmental Affairs, and Cherie McNett, director of Health Policy, had the job of developing the components of the online survey, making up a list of potential members who would receive surveys and then staying on top of them to make sure they returned them in time to be included in the “pooled” data. The RUC requires 30 valid responses for each code, and likes to see a response rate of over 30 percent. In the end, there were about 70 responses per code.

“You are supposed to randomly send the surveys to people who don’t understand the process,” explained William L. Rich III, MD, the Academy’s medical director of Health Policy. “The RUC reps can smell a cooked survey. If you try to cook the results by sending the surveys to physicians who understand the intent, the RUC will shred the presenters.”

Sound data prevail. There was nothing cooked about the Academy survey results. From start to finish, the Academy’s efforts were aboveboard. That is why the RUC and CMS found it feasible to endorse an increase in the eye visit codes’ work RVU values. And while it was Dr. Kamenetzky who successfully put ophthalmology’s case to the RUC, he is quick to point out he could make that winning play only because he was backed by sound data and the tireless efforts of an all-star team.

To get updates throughout the year on the Academy’s advocacy efforts on key issues—such as eye visit codes, the sustainable growth rate and scope of practice—check your mail for Washington Report and check your e-mail for Washington Report Express.