2017 Code Revaluations

 

The AOA is fully engaged in the American Medical Association's Relative Value Scale Update Committee (RUC). This committee is charged with valuing the CPT codes that doctors report to payers.  The code values that are recommended by the RUC are provided to the Centers for Medicare & Medicaid Services for review and for CMS to determine final valuations which directly impact reimbursement. 

All medical specialties participate in this process and virtually are specialties have been subject to reductions in the amount paid for the services and surgeries performed. From 2011-2015, the RUC made valuation recommendations to CMS for a total of 1,414 codes. From 2011-2015 codes presented to the RUC were decreased in value nearly 30% of the time.  For some other specialties, reductions in valuations have been as high as 20%. Because of the trend in valuation reductions, in 2016, CMS was forced to develop a policy to address how best to phase in double digit valuation reductions when they occur.   

In 2015 the AOA surveyed members to gain important data to present recommended code values to the RUC.  The following CPT codes were surveyed:
CPT  92132--Scanning computerized ophthalmic diagnostic imaging, anterior segment, with interpretation and report, unilateral or bilateral

CPT 92133--Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; optic nerve

CPT 92134--Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; retinal

CPT 92250-- Eye exam with photos

To gather feedback from doctors of optometry surveys for each of these individual services were disseminated to a total of 1500 doctors of optometry. In response, AOA received feedback from 92 doctors of optometry, which is equivalent to a 16 percent response rate.  Given the frequent use of CPT 92250 and CPT 92132-92134 in optometric practice and the implications of the survey, more robust feedback from doctors of optometry was expected. 

The surveys which were returned by both doctors of optometry and ophthalmologists did not support the present value of the service based upon time, effort and intensity. The RUC determined that reductions in the values for the codes were warranted. CMS finalized these reductions which will impact reimbursement in 2017.  

CPT 92132 was scheduled to be re-examined because it is considered a new technology service which requires re-valuation after three years in use. In order to establish relativity between similar codes, the RUC ordered the entire family of ophthalmic imaging codes to be resurveyed in 2015.  Survey data from doctors that report these services showed that the work associated with each code had slightly decreased since the codes were initially introduced. The final work values for each code are included below.

CPT Code

2016 Work Value

2017 Work Value

92132

0.35

0.30

92133

0.50

0.40

92134

0.50

0.45

 

Because of high and growing utilization over the past three years, CPT 92250 (Fundus Photography) was identified in 2015 as a code deserving additional review to determine if it was valued appropriately.  Following a rigorous discussion of the technique, CMS finalized a work value of 0.40 for the service, which is a relatively modest decrease from the 2016 value of 0.44. 

In addition to a close examination of the physician work involved in the performance of these studies, a similar fine tooth comb is applied to the practice expense reported for the delivery of each of these services. In like manner for all of these codes, the surveys demonstrated that a decrease in value should be assigned to the practice expense component of each of the services.

Imaging codes across all medical specialties have been subject to a film-to-digital conversion adjustment as the codes come up for review, which reduces the value of the service.   For many of the services that doctors of optometry report, an additional adjustment is being made because the services were initially valued based upon the assumption that the service took place in fully equipped examination lane.  This issue has come under scrutiny and CMS has made clear that a less expensive screening lane is a more typical location for these kinds of instruments which impacts the value of the code. 

When valuing CPT codes, many factors are considered including where the service is performed, who performs the services, the time and effort necessary to perform the service and the overall risk.  For 2017, doctors of optometry will unfortunately see the impacts of these revaluations in their reimbursement levels for these services.  For more information, contact Kara Webb at: kcwebb@aoa.org