This year, you can expect some significant modifications to how you bill and get paid. Stay ahead of the curve with this overview of the three things that might impact your practice’s billing the most — value-based payments; new and revised retina codes; and ongoing implementation of ICD-10 changes.
1. Merit-Based Incentive Payment System
The Merit-Based Incentive Payment System is the driving force behind the move from volume-based to value-based payments; it’s one of the biggest changes ophthalmologists will face this year. MIPS takes existing incentive programs and puts them all under one umbrella in order to calculate a composite performance score. This score determines whether you receive a bonus or a penalty — or simply stay neutral.
The Centers for Medicare and Medicaid Services base your composite score on your performance in four categories, each weighted by a percentage:
- Quality replaces the Physician Quality Reporting System. 2017 weight: 60 percent.
- Resource use replaces the value-based modifier program. 2017 weight: 0 percent, but CMS plans to assign a higher weight in future years.
- Advancing care information replaces the electronic health records meaningful use program. 2017 weight: 15 percent.
- Clinical Practice Improvement Activity is entirely new. 2017 weight: 15 percent.
Although CMS provides some leniency in its penalties for 2017, all physicians and practices need to be aware of their reporting options. The IRIS® Registry (Intelligent Research in Sight) provides a valuable resource for reporting your quality measures. And because it is a qualified registry, use of the registry qualifies you for percentage points in other categories, too.
To help you better understand MIPS and its impact on your practice, the Academy offers a number of resources, including “Quality Reporting in the Merit-Based Incentive Payment System,” EyeNet’s Guide to MIPS 2017 and the “Implementing MIPS in Your Practice” webinar below.
2. Coding Changes for Retina
Retina physicians face significant changes this year in billing for testing services from a combination of new and revised codes.
As of Jan. 1, the existing codes for fluorescein angiography and indocyanine-green angiography are now inherently bilateral:
- 92235 - Fluorescein angiography (includes multiframe imaging) with interpretation and report; unilateral and bilateral
- 92240 - Indocyanine-green angiography (includes multiframe imaging) with interpretation and report, unilateral and bilateral
Regardless of whether you are testing one eye or both, you can only report the code once — you can no longer bill per eye with eye modifiers or modifier -50. These new bilateral codes no longer include payment for film and development.
Also new this year, if you perform both types of angiography (FA and ICG) on the same patient during the same encounter, you can no longer bill each independently. Instead, use a new code that is also inherently bilateral:
- 92242 - Fluorescein angiography and indocyanine-green angiography (includes multiframe imaging) performed at the same patient encounter with interpretation and report, unilateral or bilateral
Although this change will likely affect your payments, the Academy advises against trying to thwart the system by scheduling patients to return for the second test at a later date. Payers will look at billing patterns and use audits and recoupment when necessary.
Finally, CMS has made significant changes to CPT surgery codes 67101 and 67105. The new versions eliminate references to outdated technology. In addition, CMS removed the phrase “one or more sessions” so that you can report treatments separately when required:
- 67101 - Repair of retinal detachment, including drainage of subretinal fluid when performed; cryotherapy
- 67105 - Repair of retinal detachment, including drainage of subretinal fluid when performed; photocoagulation
3. Delayed ICD-10 Implementation
Most physicians and their staff implemented ICD-10 coding changes on time last year. Many payers, however, were not as prepared. Practices are still dealing with claim denials and delays from payers that have not updated their systems to reflect the new and revised ICD-10 codes. In addition, many Medicare Administrative Contractors (MACs) across the country took a long time to update their local coverage determination policies, which some Medicare Advantage plans also follow.
The good news is that most of the local-coverage policies are now updated, and many MACs are reprocessing claims to expedite appropriate payments. Commercial payers, however, have been slower to respond — and still may not have updated their systems.
For more information on how all of these changes will impact you and your practice in 2017, visit the Academy’s coding and reimbursement page.
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About the authors: Jenny Edgar, CPC, CPCO, OCS, is the Academy’s coding specialist. She is also a contributing author to the Ophthalmic Coding Coach and Ophthalmic Coding series. Sue Vicchrilli, COT, OCS, is the Academy’s director of coding and reimbursement and the author of EyeNet’s “Savvy Coder” column and AAOE’s Practice Management Express, Ophthalmic Coding Coach and Ophthalmic Coding series.