This content was excerpted from EyeNet’s MIPS 2019; also see the Academy’s MIPS hub page.
The Routine Cataract Surgery with IOL Implantation measure is one of eight new episode-based measures, and it is the only one that is relevant to ophthalmology. CMS will use Medicare claims data to 1) attribute cataract surgeries to you and 2) track costs that are clinically associated with those surgeries.
Which surgeries are attributed to you? An episode of cataract surgery will be attributed to the MIPS eligible clinician who performed the procedure that “triggers” the episode. That procedure is known as the “trigger service” and the date it took place is the “trigger day.”
If you bill CPT code 66984—which is the code for routine cataract surgery—an episode of cataract surgery will be attributed to you unless an exclusion applies. Because this measure is evaluating costs for routine cataract surgery, exclusions include significant ocular conditions (such as a retinal detachment) that might impact the outcome of the surgery. CMS reviews the patient’s Medicare claims history to see if there were any ICD-10 diagnosis codes that would flag such an exclusion. (Note: Billing CPT code 66982 for complex cataract surgery would not trigger an episode.)
There is a 10-episode case minimum. The cataract measure will only contribute to your cost score if at least 10 episodes of routine cataract surgery are attributed to you in 2019.
What costs are included? The measure takes into account only the cost of items and services that are clinically related to the cataract surgery. CMS identifies those costs by reviewing the patient’s Medicare claims over a five-month period. This review period starts 60 days before the day of surgery (the trigger day) and ends 90 days after surgery (mirroring the familiar 90-day postoperative period).
CMS tries to level the playing field. Your costs for the measure will undergo payment standardization and risk adjustment. This is intended to account for cost variations that are beyond your control, such as patient characteristics that may lead to increased spending and geographic variations in wage levels.
Four subgroups. CMS recognizes that costs also might vary depending on whether surgery was done in an ambulatory surgery center (ASC) or a hospital outpatient department (HOPD), and that costs also can vary depending on whether the cataract surgery is unilateral or bilateral (which it defines as the second surgery being done within 30 days of the first).
Consequently, CMS divides episodes of routine cataract surgery into four subgroups and will only compare an episode’s costs against the cost of episodes within the same subgroup.
The four subgroups for routine cataract surgery are:
- unilateral surgery in an ASC,
- bilateral surgery in an ASC,
- unilateral surgery in a HOPD, and
- bilateral surgery in a HOPD.
(Note: The 10-episode case minimum requirement applies to the cost performance category as a whole, not to the individual subgroups.)
You score 1-10 points. You can get a score from each of the four cost subgroups, and a weighted average will be used to calculate your score for the cataract measure.
Learn more about this new measure. To learn how the new measure was developed and how it will work, read an overview by David Glasser, MD, (Ophthalmology. 2019;126(2):189-191). You also can download a detailed measure information form at the aao.org/medicare cost page (scroll down to "What You Can Do").
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