Recent Medicare fee cuts could change glaucoma practice and treatment patterns, as we reported last month. The recent consolidation of glaucoma aqueous shunt codes also stands to affect ambulatory surgical centers, eye banks and patients. Glaucoma experts explain why.
What Happened?
In January 2015, the Centers for Medicare and Medicaid Services added four new CPT codes for the large glaucoma tube-shunt family:
- 66179 Aqueous shunt to extraocular equatorial plate reservoir, external approach; without graft
- 66180 Aqueous shunt to extraocular equatorial plate reservoir, external approach; with graft
- 66184 Revision of aqueous shunt to extraocular equatorial plate reservoir; without graft
- 66185 Revision of aqueous shunt to extraocular equatorial plate reservoir; with graft
Along with these changes, CMS prevented the separate billing for aqueous shunts and patch grafts. Because ophthalmologists could no longer bill for the additional scleral-reinforcement code, the change reduced physician payments by about 30 percent.
Bundling the patch graft material also affected facility payments, which CMS calculates differently for ASCs than for hospital-based services. CMS expected the provider to pay for the material out of the ASC facility payment, but never adjusted the latter to cover the shunt and graft tissue or the other costs associated with these lengthy procedures.
The inadequate facility payment has severely affected ASCs. According to a 2015 American Glaucoma Society survey, more than 75 percent of ophthalmologists performed aqueous shunt procedures at ASCs; almost 95 percent reported using a patch graft during these surgeries. In addition, ASCs generally receive 58 percent of payments compared with hospital outpatient departments (HOPDs).
As a result, many ophthalmologists complained that they could no longer perform shunt surgeries in the ASC setting.
At first, CMS did allow for a short-term fix if the physician used donor corneal tissue. Corneal tissue for patches costs much less than the tissue required for corneal transplantation.And due to a pre-existing loophole, ophthalmologists were allowed to bill separately for this corneal patch material because the tissue was paid for by invoice.
However, despite the advocacy by AGS and the Academy, CMS rescinded the fix at the start of 2016.
How Will ASCs Respond?
“Many ASCs will lose money on tube-shunt surgery,” said David Glasser, MD, chair of the Eye Bank Association of America. Although some may continue to perform the procedure despite the loss, he predicted that other ASCs may decide that they can no longer afford to schedule these cases.
If ASCs do decline such cases, surgeons will have to shift them to the hospital setting, which CMS reimburses much more generously than ASCs. Dr. Glasser said this transition could prove disruptive for both ophthalmologists and patients: it might take a substantial amount of time for some surgeons to get hospital privileges, order instrumentation and train staff for tube-shunt surgery. In addition, patients will pay much higher coinsurance costs.
Winston Garris, MD, a glaucoma surgeon in private practice at Carolina Eye Associates, said he continues to perform tube-shunt surgeries in the ASC setting, but has been forced to adjust. “At least by using corneal (eye bank) tissue, you could continue using a technique that you were comfortable with,” he said. “Now, it’s no longer financially viable.”
As a result, Dr. Garris has converted to scleral flaps using the patient’s native tissue to keep the tube covered — a more challenging procedure, especially if the native tissue is too thin to create an appropriately thick flap. “If you are like me, in private practice and operating in an ASC that is trying to stay profitable,” added Dr. Garris, “the situation is quite the nightmare.”
Effect on Eye Banks
Surgeons aren’t the only ones who are feeling the effects. CMS’ decision has impacted eye banks as well.
After CMS' January reversal on separate payments for corneal tissue, many facilities are still trying to navigate what is and isn’t allowed, while facing significant delays in payment.
“Unfortunately, some ASCs haven’t paid attention to these reimbursement issues and are finding themselves short of funds to pay eye banks,” said Dr. Glasser. “There have been many instances where ASCs have misinterpreted the bundling of the tissue fee as meaning that tissue for tube shunts is not covered — the tissue is covered, but the tissue reimbursement is now bundled into the facility fee.”
Dr. Glasser said eye banks could also see significant drops in demand compared to what they saw in 2015. “It’s possible that some facilities may have shifted almost exclusively to corneal tissue for tube shunts prior to the January 2016 CMS rule change,” he said. “And of course now, this no longer offers a financial advantage for them.”
What the Future Holds
Because aqueous shunt surgery is reserved primarily for those in danger of severe and permanent loss of vision, the CMS changes will affect patients the most — especially those who live in underserved medical communities or have limited financial resources.
And as the number of facilities offering glaucoma aqueous-shunt surgeries shrinks, patients will have to travel longer distances or possibly be managed in a teaching hospital setting. “They will ultimately have to wait longer for surgical care,” said Arnold Prywes, MD, president of the New York State Ophthalmological Society, “especially because most hospital settings are less efficient than ASCs.”
Although it seems CMS is asking all parties to adapt, ophthalmologists believe it should not be at patients’ expense. Here’s how you can join your colleagues and fight for the highest quality patient care possible:
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About the author: Mike Mott is a former assistant editor for EyeNet Magazine and contributing writer for YO Info.