1/9/2018

2018 Coding Update

David Glasser, MD, Secretary for Federal Affairs

Sue Vicchrilli, COT, OCS, Director of Coding and Reimbursement

Topics
• 2018 Deductible, Conversion and Fee Schedule
• QPP/MIPS
• Specialty Specific Taxonomy
• Articles and Local Coverage Determinations for Testing Services
• CPT Update
• ICD-10 Update
• New Medicare Cards
• What Else You Need to Know

1
 1/9/2018

2018 Deductible
Conversion Factor
Fee Schedule

Deductible
• Medicare deductible in 2018
• $183
• Same amount as 2017

• Reminder: "Although it's not a violation for participating providers to accept

payment prior to rendering services, there are specific guidelines to follow,
especially when reporting these payments. Additionally, some providers who
accept assignment have a concern that Medicare issues partial checks to
beneficiaries. Such checks are generally issued because of a patient paid
amount in item 29 of the CMS-1500 (02/12) claim form."

2
 1/9/2018

Deductible
• When assignment is accepted, Medicare Part B recommends:
• Do not collect deductible/coinsurance amounts until Medicare Part B payment is
received since it is difficult to predict when these amounts will apply (and over-collection
is considered program abuse). In addition, this practice can cause Medicare to issue a
portion of the provider's check to beneficiaries on assigned claims.
• If you believe you can accurately predict the co-insurance amount and wish to collect it
before you receive Medicare Part B payment, note the amount collected for co-insurance
on your claim form
• Do not show any amounts collected from patients if the service is never covered by
Medicare Part B or you believe, in a particular case, the service will be denied payment.
Where patient paid amounts are shown for services that are denied payment, a portion
of the provider's check may go to the beneficiary.

Deductible
• When non-participating
• Collect the limiting charge at the time of service
• Medicare reimburses the patient directly

• If you have opted out of Medicare

• No claim is filed by the practice or patient
• Transaction between practice and patient only

3
 1/9/2018

Conversion Factor/Fee Schedule

• 2018: $35.9996
• 2017: $35.7751
• The 2% sequestration remains in effect
• Part B drugs included in QPP incentives/penalties
• Impact of 2017 Tax Cuts and Jobs Act and 2010 PAYGO Act
• Congress waived PAYGO rules in December continuing resolution
• No effect on 2018 Medicare reimbursement
• Future effects to be determined

4
 1/9/2018

Conversion Factor/Fee Schedule

CPT Code 2017 Allowable 2018 Allowable

67028 Intravitreal injection $104 Office $105 Office

$103 Facility $103 Facility

66984 Cataract surgery $654 $660

15823 Blepharoplasty $621Office $659 Office

$557 Facility $562 Facility

Conversion Factor/Fee Schedule

CPT Code 2017 Allowable 2018 Allowable

92133 $38 $39

92134 $42 $43
92083 $66 $66

92250 $67 $59

10

5
 1/9/2018

Conversion Factor/Fee Schedule

CPT Code 2017 Allowable 2018 Allowable
92004* $152 $155
99204 $167 $168
92012* $87 $90
99213 $74 $75
92014* $126 $130
99214 $109 $110

11

QPP/MIPS

6
 1/9/2018

New for 2018 in QPP/MIPS

• Threshold to avoid penalty: 15 points

• Cost = 10% of MIPS score (based on flawed attribution, risk adjustments in VBM)

• Increased low volume exemptions: <$90,000 OR <200 beneficiaries

• Increased ACI exemptions: <100 referrals (summary of care) or prescriptions (eRx)

• Relief for small practices (<15 MDs): 5 MIPS bonus points

• Acknowledgment of complex care: up to 5 bonus points

• EHR transition delay: 2015 CEHRT standard delayed till at least 2019

• Catastrophic storm relief for hurricane Irma, Harvey, Maria victims

13

New for 2018 in QPP/MIPS

• Web recording for all 4 categories of MIPS reporting in 2018:
aao.org/medicare
• Questions mips@aao.org

14

7
 1/9/2018

Specialty Specific Taxonomy

aao.org/taxonomy
• Cornea and External Disease Specialist 207WX0120X
• Available for use April 1, 2018

• To use the taxonomy, you need to be an ophthalmologist “who specializes in

diseases of the cornea, sclera, eyelids, conjunctiva and anterior segment of
the eye.”
• Other unique taxonomy specialties: Glaucoma, Neuro-ophthalmology,
Oculoplastics, Pediatrics, Retina, Uveitis

16

8
 1/9/2018

aao.org/taxonomy
• No reported problems or claim denials
• Too soon to determine impact with audits or comparative billing reports
• May be important for future CMS cost comparisons in MIPS
• Remember:
• The new codes for subspecialists are a component of ophthalmology taxonomy provider
code.
• Therefore, continue to bill any patients seen within the practice as established patients.

17

Articles and Local Coverage

Determinations for Testing Services
aao.org/lcds

9
 1/9/2018

Testing Service LCDs and Articles Updated

• Vary by Medicare Administrative Contractor (MAC) and region
• Address coverage policies:
• Documentation requirements
• List of covered diagnosis codes
• Frequency edits

• Do not apply one payer rule or perceived rule to all payers

• Frequent target of audits

19

Testing Service LCDs and Articles Updated

• Remember:
• New patients must be examined by the physician and then any medically necessary
tests are ordered.
• Standing orders or screening tests are the financial responsibility of the patient, not the
payer.
• Any test that is delegated requires a written order to include:
• Which test – by name
• Which eye(s)
• Interpretation and report provided by physician in a “timely manner”
• Chart note should reflect why it was medically necessary to perform the exam

20

10
 1/9/2018

Testing Policies by MAC

Cahaba CIGNA Government Services
VEP Pachymetry
Topography
Fluorescein angiography/ICG
Ophthalmoscopy
Fundus photo
Biometry
Scanning computerized ophthalmic diagnostic
imaging
Visual fields

21

Testing Policies by MAC

First Coast National Government Services
B-scan Pachymetry
Topography Biometry
Dry eye disease Ophthalmoscopy
Fluorescein angiography Fundus photography
Scanning computerized ophthalmic Scanning computerized ophthalmic diagnostic
diagnostic imaging imaging
ICG VEP
Ophthalmoscopy
Fundus photography
Visual fields

22

11
 1/9/2018

Testing Policies by MAC

Noridian JF only Novitas
VEP NEP
Scanning computerized ophthalmic diagnostic
imaging
VEP
Plus biometry for JL only

23

Testing Policies by MAC

Palmetto
Fluorescein angiography/ICG
Ophthalmoscopy/Fundus photography
Scanning computerized ophthalmic
diagnostic imaging
Wisconsin Physician Services
Corneal hysteresis
VEP
Scanning computerized ophthalmic diagnostic
imaging

Visual field

24

12
 1/9/2018

CPT Update

CPT Update: New Code 15730

• 15730 Midface flap (ie, zygomaticofacial flap) with preservation of vascular
pedicle(s)
• Clinical example: A 62-year-old female has an inferiorly displaced lower
eyelid and cicatricial lagophthalmos three months after excision of a
carcinoma with primary rotational flap closure. A midface zygomaticofacial
myocutaneous flap is performed to allow for adequate lid closure.
• CPT 15732 - deleted January 1, 2018

26

13
 1/9/2018

Category I Code 95930 - Descriptor Change

• Old descriptor: Visual evoked potential (VEP) testing central nervous system,
checkerboard or flash
• New descriptor: Visual evoked potential (VEP) checkerboard or flash testing,
central nervous system except glaucoma with interpretation and report
• For visual evoked potential testing for glaucoma, use 0464T
• Local Coverage Determinations aao.org/lcds

27

Category I Code 95930

• Change in reimbursement from $133 to $72
• CPT code 95930 was reviewed at the Oct 2016 RUC meeting with changes
taking effect Jan 2018.
• Work RVUs were preserved.
• PE RVUs, which is the bulk of the code’s value, were reduced significantly.
• Pre- and post-service staff time lost as these are typically done with an office visit.
• Surveys showed reduced intraservice staff time and
• Minor reductions in supply costs.

28

14
 1/9/2018

Category III Code 0333T - Description Change

• Old description: Visual evoked potential, screening of visual acuity,
automated
• New description: Visual evoked potential, screening of visual acuity,
automated, with report
• For visual evoked potential testing for glaucoma, use 0464T
• Sunset January 2019

29

Category III Code 0464T

0464T Visual evoked potential, testing for glaucoma, with interpretation and
report
• For visual evoked potential screening of visual acuity, use 0333T
• Describes visual evoked potential testing specifically for the detection of
glaucoma, in contrast to 0333T
• Separates glaucoma diagnosis from usage with existing VEP code CPT
95930
• Sunset January 2023

30

15
 1/9/2018

Category III Code 0465T

• 0465T Suprachoroidal injection of a pharmacologic agent (does not include
supply of medication)
• Code needed to describe new delivery approach with a very short needle
• Describes the microinjector developed by Clearside Biomedical
• Currently in clinical trials pending FDA approval
• Novel approach to drug delivery for uveitis, retinal vein occlusion and diabetic macular
edema

• Sunset January 2023

31

Category III Codes 0472T and 0473T

• Two new codes for the initial and subsequent programming required for the
Argus II Retinal Implant
• 0472T Device evaluation, interrogation, and initial programming of intra-
ocular retinal electrode array (eg, retinal prosthesis), in person, with iterative
adjustment of the implantable device to test functionality, select optimal
permanent programmed values with analysis, including visual training, with
review and report
• 0473T Device evaluation and interrogation of intra-ocular retinal electrode
array (eg, retinal prosthesis), in person, including reprogramming and visual
training, when performed, with review and report by a qualified health care
professional

32

16
 1/9/2018

Rationale for 0472T and 0473T

• No codes previously existed to report the postoperative custom
analysis and programming of the retinal implant.
• New codes are different from existing code 0100T (retinal
prosthesis), which only includes the surgical procedure without
any programming to make the system operational.
• Sunset 2023

33

Category III Code 0474T

• 0474T Insertion of anterior segment aqueous drainage device, with creation
of intraocular reservoir, internal approach, into the supraciliary space.
• A new drainage device is inserted into the supraciliary space via internal
approach, this will most commonly be used for Alcon CyPass.
• New code and approach differ from existing codes 0191T and 0376T:
• These describe stent placement without guide wire placement or dissection.

• Sunset January 2023

34

17
 1/9/2018

Category III Code 0474T

• CMS (not all payers) has established an allowable for the facility fee to cover
the cost of the device
• Payment of surgeon’s fee on case-by-case basis for all payers
• Patient should be informed that they may be responsible for payment

35

Category III Codes

• Reminder
• Not valued by RUC
• No CMS-wide, national allowable
• Payers must value and assign their own coverage/payment – or non-coverage
• Best to obtain an ABN and append modifier -GA for the Medicare Part B patient
• Patient may be responsible for payment

36

18
 1/9/2018

ICD-10 Codes
Effective October 1, 2017

ICD-10-CM Changes - Effective Oct 1, 2017

• 50+ new ICD-10 codes affecting ophthalmology went into effect Oct 1, 2017
• The most significant updates expand the codes for vision rehabilitation and
myopic degeneration
• Download copies of decision trees at aao.org/icd10

• Medicare much more prompt in updating LCDs this year

38

19
 1/9/2018

Myopic Degeneration
• January 2017 FDA approved Lucentis as a treatment for patients
with choroidal neovascularization (CNV or mCNV) resulting from myopic
macular degeneration (MMD), also known as myopic degeneration.
• Not refractive error!

• No change in the drug units: still 5 units

• Documentation should include any residual drug discarded

39

Vision Rehabilitation
• ICD-10 did not include laterality
• Many prior payment policies in ICD-9 were based on a change in either eye
• Expanded section to allow changes in each eye and for the patient to be
reported

40

20
 1/9/2018

New Medicare Cards

New Medicare Cards aao.org/mbi

• Bye, bye SSN
• Hello MBI
• Medicare Beneficiary Identifier

• Medicare patients will start receiving the new cards in April 2018
• Watch for your letter from CMS in the mail

42

21
 1/9/2018

New Medicare Cards aao.org/mbi

• The new cards will have a unique, randomly assigned number instead of a
social security number
• Make sure your software can accept

• To prepare for this change, CMS is establishing a 21-month transition period:

April 1, 2018, to Dec. 31, 2019
• Good news: During the transition, CMS will accept both the new and old
numbers

43

What Else You Need to Know

22
 1/9/2018

Height/Weight Anti-VEGF Drugs

• Anthem has been denying claims when height/weight not documented prior
to anti-VEGF drug injections
• Correction made through Academy efforts
• Effective first quarter of 2018
• Until then, enter 1 on each line for ht/wt or go through the call center to work around the
issue

45

Vitrectomy National Coverage Determination

• Erroneously eliminated approximately 351 diagnosis codes including those
for vitreous hemorrhage, macular hole and macular pucker
• The deletions were part of an effort to clean up its volume of ICD-10 codes
associated with national coverage decisions
• Consider holding your claims until a fix is announced

46

23
 1/9/2018

Modifier -25 and Anthem BCBS

• In targeted states, Anthem BCBS has proposed reducing exams by 50
percent of the allowable, when appended with modifier -25 (indicating a
minor surgical procedure performed the same day).
• Ongoing conversation with Anthem and AAO and other state and medical
associations resulted in:
• Delay of implementation until March 2018
• 25% rather than 50%
• Communications continue!

47

Pediatric Claim Denial Ongoing Issue

• AAO and AAPOS ongoing communication with commercial payers who deny
amblyopia family of diagnosis as “routine”

48

24
 1/9/2018

Modifier -GT Deleted

• -GT Via interactive audio and telecommunication systems
• Deleted as place of service 2 indicates telemedicine service has been
provided, so appending the modifier is redundant

49

CCI Edits
• Minimal CCI edits impacting ophthalmology effective January 1
• 20 CPT codes bundled with 15730 Midface flap and 15733 Muscle flap

• CCI edits can be found:

• aao.org/coding
• Coding Coach: Complete Ophthalmic Coding Reference
• Retina Coding: Complete Reference Guide

50

25
 1/9/2018

MIGS Payment Update

• MACs reviewing 0191T iStent allowable and reducing to $300 +/- range
• Will not be reduced by 50 percent when performed in conjunction with cataract surgery

• Newer Category III codes such as 0474T CyPass, if covered, are carrier
priced
• Best to obtain an ABN from the Medicare Part B patient
• For non-Medicare payers, preauthorization is not a guarantee of payment
• Ask for an allowable

51

MIGS Overview
0191T Insertion of anterior segment aqueous • iStent
drainage device, without extraocular • In conjunction with cataract
reservoir; internal approach, into the surgery
trabecular meshwork; initial insertion • Medicare benefit
• Coverage varies by commercial
plan
• Carrier priced

+0376T Each additional device • Not separately billable to Medicare

• If commercial plan doesn’t cover
0191T, patient is responsible for all
devices inserted

26

MIGS Overview
0253T Insertion of anterior segment
aqueous device, without extraocular
reservoir, internal approach, into the
suprachoroidal space
MIGS Overview
0449T Insertion of aqueous drainage
device, without extraocular
reservoir, internal approach,
into the subconjunctival space;
initial device
+0450T Each additional device
1/9/2018
• iStent Supra Micro-Bypass Stent
• With or without cataract surgery
• Coverage is payer specific
• XEN Gel Stent
• With or without cataract
surgery
• Coverage is payer specific
• Not separately billable to
Medicare
• If commercial plan doesn’t
cover 0449T, patient is
responsible for all devices
inserted
27
 1/9/2018

MIGS Overview
0474T Insertion of anterior segment • CyPass
drainage device, with creation of • In conjunction with cataract
intraocular reservoir, internal surgery
approach, into the supraciliary • Coverage is payer specific
space

MIGS Overview
66174 Transluminal dilation of aqueous • Includes ABiC (ab interno
outflow canal; without retention of approach without flaps)
device or stent • With or without cataract
surgery

28
 1/9/2018

Cahaba to Transition to Palmetto GBA

• Alabama, Georgia, Tennessee
• Part A to transition January 29, 2018
• Part B to transition February 26, 2018

57

Office of Inspector General

• The OIG Work Plan sets forth various projects including OIG audits and
evaluations that are under way or planned to be addressed during the fiscal
year and beyond by OIG's Office of Audit Services and Office of Evaluation
and Inspections.
• December 2017 Medicare Advantage (MA) organizations submit to CMS diagnoses on
their beneficiaries; in turn, CMS categorizes certain diagnoses into groups of clinically
related diseases called hierarchical condition categories (HCC). For instances in which a
diagnosis maps to a HCC, CMS increases the risk-adjusted payment.
• Specifically, we will review instances in which CMS made an increased payment to an
MA organization for a HCC and determine whether CMS's systems properly contained a
requisite diagnosis code that mapped to that HCC.

58

29
 1/9/2018

What’s Coming in the Future

• Revisiting E/M documentation requirements
• What changes or when they will occur is unknown

• Watch PME and WRE for ongoing updates

59

Additional Questions?
• Coding
• website: aao.org/coding
• email: coding@aao.org

• ICD-10
• website: aao.org/icd10
• email: icd10@aao.org

• MIPS
• website: aao.org/medicare
• email: mips@aao.org

60

30
1/9/2018

31