• Academy Outlines Key Concerns About Proposed Medicare Fee Schedule


    Global surgical payments and values for MIGS, cataract surgery and strabismus codes are among the key targets of our latest effort to show CMS where it needs to adjust its proposed 2022 Medicare physician fee schedule.

    Patient access constraints and increased strain on ophthalmology practices that are already under severe financial pressure due to the public health emergency could result if the Centers for Medicare & Medicaid Services finalizes its proposal.  

    In our continued efforts to advocate for ophthalmology, the Academy this week submitted formal written comments to CMS on the proposed fee schedule. Here are some highlights of our response. For a more detailed analysis, read our comments in our letter to CMS (PDF).

    The proposed fee schedule is estimated to have an expected 3.75% reduction to ophthalmology and other specialties with the expiration of a one-year boost that Congress provided for 2021. The Academy believes that CMS should resolve the negative effects of several proposed policy changes, outlined below, on physicians who provide care for Medicare beneficiaries.

    Global Surgical Payments

    Even after substantial advocacy from the surgical community, CMS made no mention in the proposed rule of applying evaluation and management (E/M) payment equity to post-operative visits included in the global surgical payment. The Academy continues to urge CMS to apply E/M payment increases to postoperative visits in the global codes to ensure equitable treatment to surgical specialties. The Academy along with the American Society of Cataract and Refractive Surgery and other groups from the Surgical Care Coalition met with CMS last week to discuss this issue. We believe CMS has the ability to make this change in the final 2022 final schedule due in November.

    Specific Coding Issues

    MIGS, Cataract Surgery

    The Academy strongly disagreed with CMS’ proposed work values for new combo CPT codes 669X1 and 669X2:

    • CMS proposed a 10.31 work relative value unit (WRVU) for 669X1 while the RVS Update Committee (RUC) recommended 12.13.
    • CMS proposed a 7.41 WRVU for 669X2 while the RUC recommended 9.23.

    We urged CMS to reconsider its proposal and increase the payment rates for these new codes.

    The CMS value proposals result in a payment for CPT 669X1 that would be only $3 more than the complex cataract surgery reimbursement rate, and the payment for CPT 669X2 would be only $34 more than cataract surgery alone. It will create access issues for patients needing this critical sight-saving eye care. CMS’ proposal completely fails to recognize that inserting the drainage device requires substantial time over and above that required for just the cataract or intraocular lens surgery.

    The Academy told CMS these proposed values are illogical and destroy the relativity between this family of procedures within the resource-based relative value scale (RBRVS), which is the physician payment system used by CMS. 

    We urged CMS to accept the RUC methodology and RUC-recommended WRVUs, which remain the most accurate means available for valuing the physician work associated with CPT 669X1 and CPT 669X2. Further, we told CMS if it cannot accept the RUC-recommended values for 2022, then it should allow for carrier pricing until the time of the new technology review by the RUC. Carrier pricing would allow each Medicare Administrative Contractor to set its own price for the codes absent a national price from CMS.

    We appreciate you answering the Academy’s call to action on this issue and sending a total of 318 letters to CMS asking them to rethink this proposal. Your advocacy will be critical to our success.

    Strabismus

    Although CMS proposed to adopt the RUC recommendations for the family of 11 strabismus surgery codes (CPT 67311-67340), the Academy is concerned about the effect of these dramatic reductions.

    We know these payment reductions for strabismus surgery, ranging from 7% to 22%, are going to be challenging for ophthalmologists.

    The Academy urged CMS to phase in these reductions over a longer time period than normal. We recommended that they be implemented in equal amounts over three years, rather than the typical 19% reduction the first year.

    We pointed out that CMS has an opportunity to further mitigate the effect of these cuts by improving the Medicare payment for these global codes through equity adjustments to the built-in E/M post-operative visits. For example, if CMS restores post-operative payment equity in the fee schedule, the estimated cut to CPT 67311 falls from 22% to about 14%. 

    Again, we appreciate you answering the Academy’s call to action on this issue and sending a total of 82 letters to CMS telling them the cuts will negatively affect access for vulnerable children and further exacerbate the existing disparities in the diagnosis and treatment of pediatric strabismus.

    See the Academy’s full comments for additional coding change comments (PDF).

    Health Equity

    The Academy applauded CMS for its focus on health equity. We discussed several opportunities for CMS to reduce health disparities and improve care for Medicare beneficiaries through appropriate physician reimbursement related to the use of innovative technologies. We specifically highlighted examples such as pediatric ophthalmology surgery, remote retinal imaging and glaucoma surgery. We are hopeful that CMS’ focus on health equity will lead to positive policy changes in the final rule, helping to ensure all communities and beneficiaries have access to innovative sight-saving technology and services.

    Telehealth Provisions

    The Academy supports CMS’ proposal to continue paying for services placed temporarily on the telehealth list through the end of 2023. Broadly, the Academy has been very supportive of proposals to expand telehealth coverage especially during the public health emergency when in-person visits have been challenging.

    Quality Payment Program

    As we previously told you, CMS is continuing to advance the Merit-Based Incentive Payment System (MIPS), and in performance year 2022 it will be harder to avoid the 9% payment penalty paid out in 2024.

    Although we appreciated many of the MIPS flexibilities CMS implemented in light of the ongoing public health emergency, we highlighted several flexibilities and delays that CMS should continue for 2022.

    Specifically, we asked that CMS delay removal of MIPS quality measures. We commented that without measures that span specialties and can be collected without electronic health records, CMS is disadvantaging small and rural practices that are providing necessary care for patients. 

    The Academy urged CMS to provide additional points towards the promoting interoperability and quality categories for practices that participate in the Academy’s IRIS Registry through electronic health records integration. The Academy believes practices and practitioners that are EHR-integrated with Qualified Clinical Data Registries should continue to earn bonus points for their quality measurement and earn additional bonus points under the Promoting Interoperability category. We also called for increased transparency in several areas of the Quality Payment Program.

    MIPS Value Pathways and Alternative Payment Models

    CMS requested specific public comments on its goal to sunset traditional MIPS and move to MIPS Value Pathways (MVPs) or Advanced Alternative Payment Models (APMs) after the 2027 reporting year. MVPs are a subset of measures and activities, established through rulemaking, that can be used to meet MIPS reporting requirements. APMs are a track of the Quality Payment Program that offers a 5% incentive payment for achieving threshold levels of payments or patients through Advanced APMs. If you achieve these thresholds, you become a Qualifying APM Participant (QP) and you are excluded from the MIPS reporting requirements and payment adjustments.

    At this time, ophthalmologists and other physicians have no MVP option available and do not fit into most existing APMs. Without the fee-for-service option of traditional MIPS, ophthalmologists and other physicians would be left without a reporting method to avoid penalties. The Academy pushed CMS for more information as to how the agency plans to handle clinicians who do not have MVPs or APMs available for reporting and what CMS plans to do to make it possible for these clinicians to avoid penalties.

    See the Academy’s full comments for more detailed responses to CMS on QPP proposals for 2022 (PDF).

    The final Medicare Physician Fee Schedule and Quality Payment Program rules are expected to be released in November. For more information, contact healthpolicy@aao.org or mips@aao.org