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What's New in 2017?

A Reimbursement and Compliance Update for Eye Care Providers

Donna M. McCune, CCS-P, COE, CPMA

Corcoran Consulting Group

The recent election raises questions about the future of health care in the United States. Will the Affordable Care Act (Obamacare) and CMS’ new Quality Payment Program be revised or rescinded? It is too early to tell. We can speculate about the future, but for now you can prepare for reimbursement, coding, and regulatory changes impacting your practice in January 2017.

Physician Reimbursement

The 2017 Physician Fee Schedule Rule, published in the Federal Register on Nov. 15, 2016, is the second since the repeal of the Sustainable Growth Rate (SGR) formula by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). The law instituted a 0.5% update to Medicare physician payments for five years.

The 2017 conversion factor is $35.8887, which is a slight increase from the 2016 conversion factor of $35.8043. It includes a budget neutrality adjustment of -0.013%, an increase of 0.5% resulting from MACRA, and a misvalued code reduction target adjustment of -0.18%. Additionally, relative value unit (RVU) changes for some CPT codes occur on Jan. 1. Of the 553 CPT codes that apply to ophthalmology and optometry within the Medicare program, 526 of them changed very little: 3% or less. Nine procedures had substantial increases in reimbursement; 18 had substantial reductions in reimbursement (see the bullet points below). The average change in Medicare reimbursement rates for ophthalmic services is miniscule (0.01%). Some retina and glaucoma procedure codes were favorably revalued after significant reductions in 2016. Others were reduced when the postop period was shortened to 10 days.

Below is a sampling of CPT codes with substantial changes:

Repair RD laser (67105)* -59%
Repair RD cryotherapy (67101)* -58%
Probe NLD (68810) -19%
Probe NDL (68811) -18%
Dilate punctum (68801) -12%
Trabeculoplasty (65855) -10%
Orthoptics (92265) +8%
Repair RD buckle (67107) +12%
Trabeculectomy (66170) +13%
Repair RD pneumatic retinopexy (67110) +16%
Corneal hysteresis (92145) +19%

*These procedures were changed from major surgeries (90-day postop) to minor surgeries with a 10-day post-operative period as of Jan. 1, 2017.

Ophthalmic Imaging

In 2017, Medicare reimbursement for all ophthalmic imaging services is dramatically reduced (Table 1). The redefining of angiography as a bilateral service magnified the reduction. Formerly, angiography was paid per eye.

Table 1: Medicare Payments for Ophthalmic Imaging
CPT Description 2016     2017 Change %
92235 Fluorescein angiography* $111 $87 -61%
92240 ICG angiography* $257 $211 -59%
92242 FA & ICG* N/A $230 N/A
92250 Fundus photography $79 $67 -16%
92132 SCODI, anterior $35 $32 -10%
92133 SCODI, optic nerve $44 $38 -14%
92134 SCODI, retina $45 $42 -8%
*In 2017, these procedures are defined as bilateral services.

Facility Reimbursement

Various adjustments to hospital reimbursement result in a Hospital Outpatient Department (HOPD) rate increase of 1.65%.

For 2017, the wage adjustment for budget neutrality in addition to the multifactor productivity adjusted update factor increases the ASC conversion factor by 1.9% for those meeting the quality reporting requirements (resulting in small increases in facility reimbursement). ASCs began reporting National Quality Forum Measures in October 2012. The reporting of these measures affects reimbursement. Nonparticipation or failure to meet the necessary requirements results in a 2% reduction to ASC Medicare reimbursement. No new measures were added in 2017, which would affect payments in 2019. Seven additional measures were finalized for implementation in 2018, affecting 2020 payments.

In 2017, CMS continues its policy that corneal tissue acquisition cost is only reimbursed when used in corneal transplant surgery.

Data Collection on Global Periods

As of Jan. 1, 2017, MACRA Section 1848(c)(8)(B) requires collection of data to value global surgical packages. The final rule includes the following:

  • Submit with CPT code 99024
  • Applies to groups with 10 or more practitioners
  • Only in certain states: Florida, Kentucky, Louisiana, Nevada, New Jersey, North Dakota, Ohio, Oregon, and Rhode Island
  • Report services reported annually by more than 100 practitioners and more than 10,000 times or have allowed charges in excess of $10 million annually
  • Mandatory reporting July 1, 2017
  • Can report beginning Jan. 1, 2017

The final list of codes will be posted to CMS website.

CPT Coding Update

The 2017 CPT manual contains new codes, revisions, and deletions applicable to ophthalmology and optometry. Category I CPT code changes are as follow:

New code:

  • 92242 — Fluorescein angiography and indocyanine-green angiography (includes multiframe imaging) performed at the same patient encounter with interpretation and

The following codes contain language changes described by underlines and represent clarifications and, in some cases, substantive revisions.

  • 67101 — Repair of retinal detachment, 1 or more sessions; cryotherapy or diathermy including drainage of subretinal fluid when performed; cryotherapy
  • 67105 — Photocoagulation including drainage of subretinal fluid, when performed
  • 92235 — Fluorescein angiography (includes multiframe imaging) with interpretation and report, unilateral or bilateral
  • 92240 — Indocyanine-green angiography (includes multiframe imaging) with interpretation and report, unilateral or bilateral

Deleted in 2017:

  •  92140 — Provocative tests for glaucoma, with interpretation and report, without tonography

Released semiannually by the American Medical Association (AMA), new Category III codes became effective Jan. 1, 2017, following the six-month implementation period that began July 1, 2016.

  • 0444T — Initial placement of a drug-eluting ocular insert under one or more eyelids, including fitting, training, and insertion, unilateral or bilateral
  • 0445T — Subsequent placement of a drug-eluting ocular insert under one or more eyelids, including re-training, and removal of existing insert, unilateral or bilateral
  • 0449T — Insertion of anterior segment drainage device, without extraocular reservoir; internal approach, into the subconjunctival space
  • +0450T — Each additional device (List separately in addition to code for primary procedure; For removal of aqueous drainage device without extraocular reservoir, placed into the subconjunctival space via internal approach, use 92499)

Two new and one revised Category III codes are effective Jan. 1, 2017, and will be published in the 2018 CPT manual:

  • 0464T — Visual evoked potential, testing for glaucoma, with interpretation and report (For visual evoked potential screening for visual acuity, use 0333T)
  • 0465T — Suprachoroidal injection of a pharmacologic agent (does not include supply of medication) (To report intravitreal injection/implantation, see 67025, 67027, or 67028)
  • 0333T — Visual evoked potential, screening of visual acuity, automated, with report

Coverage and payment for Category III codes remains at the discretion of the Medicare Administrative Contractor (MAC).


Implemented on Oct. 1, 2015, the ICD-10 transition was relatively smooth. Unfortunately, the first major update of ICD-10 codes on Oct. 1, 2016, has not been smooth for some. The update includes 1,974 new codes, 311 deleted codes, and 425 revised codes. Major updates occurred in the open angle glaucoma series, diabetic eye diseases, AMD, and vein occlusions. Some MACs were tardy updating local policies or did so incorrectly, resulting in inaccurate claim denials.


As telehealth continues to evolve in health care, so do coding changes to designate such services. Effective Jan. 1, 2017, a new place of service, POS 02 — Telehealth, becomes effective. Described as: “The location where health services and health related services are provided or received, through telecommunication technology,” it is used by the physician or practitioner furnishing telehealth services from a distant site. In the same CMS instruction document on the new POS, it reminds providers that one of two modifiers is required when billing Medicare for Telehealth services.

  • GT — Via interactive audio and video telecommunications systems
  • GQ — Via an asynchronous telecommunications system

These modifiers are published in the HCPCS Manual. A new Telehealth modifier was assigned in Appendix P of the 2017 CPT manual.

  • 95 — Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System

This modifier may only be appended to a specific list of CPT codes for services typically performed face- to-face but may be rendered via real-time (synchronous) interactive audio and video telecommunications system.

Regulatory Update

The annual publication of the Office of Inspector General (OIG) Work Plan contains a few targets for scrutiny that are of concern to ophthalmologists and optometrists. The targets are:

  • Drug Waste of Single Vial Drugs (new)
  • Management Review: CMS’ Implementation of the Quality Payment Program (new)
  • ASC — Quality Oversight
  • Anesthesia services — Payments for personally performed services

CMS awarded new contracts for Recovery Auditors on Oct. 31, 2016. Three companies will cover five regions. The breakdown is as follows:

  • Region 1 — Performant Recovery, Inc.
  • Region 2 — Cotiviti, LLC
  • Region 3 — Cotiviti, LLC
  • Region 4 — HMS Federal Solutions
  • Region 5 — Performant Recovery, Inc.

The recover auditor contractors (RACs) listed for Regions 1–4 perform postpayment reviews for Medicare Part A and B for all provider types except Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) and Home Health/Hospice. Region 5 will handle DMEPOS and Home Health/Hospice.

The new contracts stipulate audit timelines that reduce the look-back period on claims. In addition, RACs now receive payments only after a provider has exhausted two levels of appeal. Since its inception in 2010, the program has recouped approximately $9.5 billion.

Strategic Health Solutions, LLC, contracted by CMS as a Supplemental Medical Review Contractor (SMRC) in Sept. 2012, conducts nationwide medical reviews as directed by CMS. Similar to RACs, SMRCs must publish their projects on their website. At this time, three projects involve ophthalmology. They are:

  • Project Y3P0225 — Blepharoplasty and Other Related Facial Procedures
  • Project YP0435 — Ranibizumab (Lucentis)
  • Project YP0439 — Ophthalmology Services

The description of these projects focus on utilization issues and questionable billing practices for ophthalmic services.

The amount in controversy to take an appeal to an Administrative Law Judge (ALJ) increased to $160; $1,560 to take an appeal to the Federal District Court. These are small increases from the 2016 levels.

Beneficiary Issues

The Medicare Part B basic premium increased to $109.00 for most beneficiaries. The Part B deductible increases to $183. This is a $17 increase from the 2016 deductible.

Quality Payment Programs

MACRA consolidates current quality reporting programs — PQRS, EHR Meaningful Use, and the Value- Based Payment Modifier — into a new program: the Merit-Based Incentive Payment System (MIPS). The law stipulates a Jan. 1, 2017, start date, but the first bonus or penalty occurs in 2019, based on a two- year look back.

The penalties associated with the current quality reporting programs sunset after 2018. To avoid a PQRS penalty in 2018, you must satisfy the 2016 reporting requirements. Failure to do so results in a 2% PQRS penalty and a potential additional adjustment for the Value-Based Payment Modifier.

The 2015 Electronic Health Record Flexibility Rule revised the requirements for Meaningful Use (MU) attestation. For 2015-2017, all eligible professionals must report on 10 mandatory objectives included in the Modified Stage 2 Rule. Failure to attest for 2016 participation results in a 4% penalty in 2018. Providers who have already attested to MU in prior years are required to report MU for any continuous 90-day period in 2016 and 2017. Reporting deadline for 2016 is Feb. 28, 2017. If a provider is attesting   for the first time for 2016 participation, attestation by Feb. 28, 2017, avoids a 2018 penalty.


John F. Kennedy said “Change is the law of life. And those who look only to the past or present are certain to miss the future.” In 2017, numerous changes are in store for ophthalmologists and optometrists. Your success relies on being informed of the changes and responding to them.

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