October 2019


Cataract surgery code valuations

Q&A between Nick Mamalis, MD, and Parag Parekh, MD

Watch Nancey McCann, ASCRS Government Relations, discuss the proposed rule on
EyeWorld TV at bit.ly/2lifLar


Dr. Mamalis: Can you provide an overview of the RUC process and how codes are revalued?

Dr. Parekh: Since the early 1990s, Medicare physician reimbursement has been determined through the resource-based relative value scale (RBRVS), which assigns value to all physician services based on three components: work, practice expense, and malpractice values. In this budget-neutral system, each of these components for a given service are assigned specific relative value units (RVUs) that are adjusted for geographic price differences if necessary, added together, and multiplied by the conversion factor to arrive at a dollar figure, which is what Medicare reimburses the physician. Since the fee schedule is budget neutral, meaning that changes in RVUs cannot cause expenditures to increase or decrease more than $20 million, CMS also makes adjustments to the conversion factor to maintain budget neutrality.
Work RVUs are based on the time and intensity required to furnish the service and determined through the RUC process. The RUC is made up of physicians from 31 different specialties and is charged with regularly reviewing and updating the values for more than 10,000 different physician services. When a code is identified for review by the RUC, medical societies whose members perform the service are tasked with surveying their members on the work required for the service and developing a recommendation to the RUC based on the survey results. Because the value must be relative to all other services, the presenters must crosswalk to other services with similar time and intensity to justify their requested value. The RUC deliberates on the data presented and makes a recommendation to the Centers for Medicare and Medicaid Services (CMS). CMS can either accept the RUC recommendation or make further refinements to the value.

Dr. Mamalis: Why was cataract surgery targeted for review?

Dr. Parekh: All services must be periodically reviewed, usually every 5 to 7 years. A subcommittee of the RUC, the Relativity Assessment Workgroup (RAW), uses various criteria to prioritize review, such as codes that are potentially overvalued or have significant changes in utilization. In our case, data showed that when a low volume code, 66711 ciliary body destruction, was billed, more than 75% of the time it was in conjunction with cataract surgery. This necessitated a new CPT code that combined the two services and a revaluation of all the codes in that “family,” including cataract surgery.

Dr. Mamalis: Can you describe ASCRS’s and AAO’s survey process and recommendation?

Dr. Parekh: ASCRS and AAO conducted an anonymous random survey of about 1,500 of our members and received 93 responses, which exceeded the minimum of 75 responses necessary for codes of this volume. The survey focused on all the work associated with the procedure—the pre-, intra- and post-service, as well as the E/M office visits included in the 90-day global postoperative period. The survey found that since the previous revaluation 6 years ago, the pre- and post-service time decreased by 4 minutes, the intra-service time decreased by 1 minute, and there were three postoperative visits furnished, down from the current four visits. Survey participants were significantly uniform in their responses.
The cataract procedure’s intensity has always been an integral factor in determining the value. Intensity includes mental effort and judgement, technical skill, physical stress, and psychological stress. Because the surgeon must be inside the eye for the entire procedure, cataract surgery has a higher intensity value than almost any other surgery, including neuro- and cardiac surgery. So while the RUC recommended a significant cut because of the lost
postoperative visit (accounting for about $75 of the reduction), ASCRS and AAO were successful in presenting the intensity argument. To do this, we took an incremental approach and identified a retina code with a similar work RVU but slightly shorter time. We calculated the intensity per minute of intra-service time for the retina procedure, then used that intensity per-minute value for each of the 5 additional minutes of intra-service work for cataract surgery. Therefore, we were able to prevent a much deeper cut of perhaps 40–50% that would have aligned the value with other less intense surgical codes with similar operative time and number of postoperative visits. While we certainly do not want to diminish the significance of the cut in 2020, we were pleased that RUC recommended the value it did and that CMS accepted it.

Dr. Mamalis: Why didn’t ASCRS or AAO inform members of this reduction previously?

Dr. Parekh: All participants at the RUC—members, presenters, observers, and staff—must sign a confidentiality agreement and may not discuss the deliberations of the meeting until CMS publishes the proposed rule in the Federal Register. In addition, CMS is under no obligation to accept the RUC’s recommendations; CMS can cut services more than what the RUC suggests and, in fact, for many services CMS did just that. Therefore, we did not know what the proposed value would be. Despite those limitations, the RUC-approved messages sent by both ASCRS and AAO alerted our members that the cataract code was being revalued and encouraged members who received the survey to complete it.

Dr. Mamalis: What are the next steps?

Dr. Parekh: CMS is also proposing to increase the values of office visit E/M codes beginning in 2021. However, it is not proposing to increase the value of postoperative visits included in global surgery codes, even though the RUC values them equally to standalone E/M codes. Because E/M services are by far the most billed physician services and the system is budget neutral, the increased value is expected to have a negative impact on all other services in the fee schedule beginning in 2021. ASCRS is working with the AMA and the surgical community to advocate that CMS extend the E/M increases to those 10- and 90-day global codes to ameliorate some of the impact. If this change is made, it would increase the RVUs for the cataract code to 8.23, restoring almost all of the value lost as a result of this revaluation. We are cautiously optimistic that CMS will make this change when the final rule is released in November.
In addition, we are seeking congressional action to extend positive updates to the conversion factor originally enacted as part of the Medicare Access and CHIP Reauthorization Act (MACRA) that are set to expire beginning in 2020.

Dr. Mamalis: What resources has ASCRS developed to help members understand this change in reimbursement?

Dr. Parekh: ASCRS has provided several resources on its website, such as additional background information, tools to help understand the impact on practices, as well as a video and a webinar.

About the doctors

Nick Mamalis, MD
ASCRS President

Parag Parekh, MD
ASCRS Government Relations Committee Chair

Since the release of the 2020 Medicare Physician Fee Schedule proposed rule that included revised cataract surgery values, ophthalmologists have been asking questions about how and why the revaluation came to be and what the impact will be on their practices. ASCRS Government Relations Committee Chair Parag Parekh, MD, has represented our society at the American Medical Association’s Relative Value Update Committee (RUC) for the past several years. Subspecialty societies join with the American Academy of Ophthalmology (AAO) to defend the value of ophthalmic services; for example, the American Society of Retina Specialists worked with AAO on the retina injection codes, and ASCRS worked with AAO to defend cataract codes. As our RUC representative, Dr. Parekh has a front-row seat to see how these decisions get made and what ASCRS does to advocate for our members.

—Nick Mamalis,
ASCRS President

For more information visit:

Contact information

: nick.mamalis@hsc.utah.edu
Parekh: parag2020@gmail.com

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