Ask the Coding Experts, by Doug Morrow, O.D., Harvey Richman, O.D., Rebecca Wartman, O.D.
From the May 2016 edition of AOA Focus, pages 42-43.
Recent changes in the health care delivery and reimbursement systems have called into question the value and future use of Current Procedural Terminology (CPT®) coding. With new care delivery systems, such as accountable care organizations, and with the new Merit-based Incentive Payment System (MIPS) on the horizon, many wonder: Will the codes we use in our practices every day be useful in the future?
While the future is always uncertain, here is what we do know:
Fee for services in Medicare remains
The Medicare Access and CHIP Reauthorization Act (MACRA) was signed into law in April 2015. The legislation permanently repeals the Sustainable Growth Rate formula and gives physicians new options for reimbursement under Medicare. Beginning in 2019, the Centers for Medicare & Medicaid Services (CMS) will implement a reimbursement system with two tracks. Most physicians will likely enter into track 1, which builds upon the current fee-for-service system and current incentive programs under Medicare.
Track 1: Merit-based Incentive Payment System (MIPS)
MIPS, a new CMS program, retains the fee-for-service model—of which CPT coding is a critical component—and combines the Physician Quality Reporting System, the Value-based Payment Modifier, and the Medicare Electronic Health Record (EHR) Incentive Program. Doctors in this track are evaluated based on four performance categories:
- Resource use
- Meaningful use of certified EHR technology
- Clinical practice improvement activities
Based on performance in each of the categories, physicians receive a composite performance score. That score will determine whether a physician receives an incentive or a penalty. CPT coding will remain under MIPS in order for physicians to appropriately communicate the services rendered.
Track 2: Alternative payment model participation
Physicians can choose to participate in a qualifying alternative payment model (APM), if the APM meets the following criteria:
- Uses quality measures
- Uses certified EHR technology
- Bears more than nominal financial risk or is a medical home expanded under the Centers for Medicare and Medicaid Innovation model
- Has increasing percentage of payments linked to value through Medicare or all-payer APMs
It is anticipated that even with new payment models, CPT coding will remain necessary to report services.
CPT panel and Relative Value Scale Update Committee prioritization
AOA is fully engaged in both the CPT code development process and the code valuation process through its work with the CPT Editorial Panel and the Relative Value Scale Update Committee (RUC). Both of these bodies have dedicated committees that are working to address changes in care delivery and reimbursement. These committees are evaluating how to code and value team-based care, how to develop codes for care management/collaboration and advanced payment models. These groups of coding and valuation experts also are aware of the need for these bodies to move swiftly and efficiently to develop new codes that correspond with new models of care that are developed. AOA will remain engaged with CPT and the RUC to ensure the care that doctors of optometry provide is appropriately described and valued, regardless of changes made to the current fee-for-service structure.
Health Insurance Portability & Accountability Act of 1996 (HIPAA) CPT requirements
Under HIPAA, the Department of Health and Human Services (HHS) was directed to adopt specific code sets for diagnoses and procedures to be used in all health care transactions. Through the regulatory process, CPT was specifically delineated as a procedure code set to be used in health care transactions. This recognition by HHS for CPT solidifies its importance in health care.
While changes are on the horizon, CPT coding will remain a component of practice. To ensure you are appropriately coding, visit the AOA Marketplace to obtain all the coding resources you need.
Ask the coding experts
Evaluation and management (E/M) services are incredibly important in patient care, and it’s critical that optometry practices are aware of changes ahead. Meanwhile, the AOA and other leading physician organizations are pushing legislation that would halt Medicare payment cuts resulting from the changes.
Time to review your practice’s billing and coding: Access national benchmark data for optometry practices and join an upcoming webinar to learn more about E/M code changes in 2021.