EyeWorld/ASCRS reporting live from ASCRS Winter Break in Park City, Utah, Friday, January 31, 2020


EyeWorld/ASCRS reporting live from ASCRS Winter Break in Park City, Utah, Friday, January 31, 2020
The second day of the ASCRS Winter Break meeting featured presentations on glaucoma, refractive cataract surgery, legislative and regulatory issues, and the Crandall Lecture.
Glaucoma topics

The first session of the day took a look at a variety of topics in glaucoma. During his presentation, Manjool Shah, MD, Ann Arbor, Michigan, shared some possible complications with MIGS.

Though MIGS generally have a high safety profile and low risk of complications, Dr. Shah noted that every procedure has its own challenges, pitfalls, and complications.

He shared a case of an “over filtering iStent.” An 80-year-old patient with a history of mild POAG presented with cloudy vision, pain, and nausea to an emergency department. She was diagnosed there with acute angle closure, and upon arrival to Dr. Shah’s department, her pressure had reduced, and she had mild corneal edema. Dr. Shah discovered that the patient had cataract surgery and iStent (Glaukos) 3 years prior. Despite being told that the surgery was uncomplicated, she had hypotony and eventually underwent iStent explantation to correct the over filtering. However, Dr. Shah discovered that the actual problem was a cyclodialysis cleft, which he noted are often small and localized. He was able to fix it easily.

Another case he shared was that of an “overexuberant iStent implantation.” One challenge with iStent inject (Glaukos) is potentially going too deep, Dr. Shah said. If it’s not connected to the anterior chamber, it won’t really do anything, he said. To fix it, first you have to know where you were (and heme reflux may guide you). Micro forceps make this somewhat easier, Dr. Shah said.

Dr. Shah also shared a number of pearls when using the Hydrus Microstent (Ivantis). He recommended using a separate incision, adding that it’s helpful to be 4-clock hours away from the intended entry. He also said that a small paracentesis helps you maintain the chamber and allows you to rotate the eye a bit. He also said to know your anatomy, adding that a long, rigid misaligned stent can be trouble. Finally, he said to engage the canal at an upward angle and flatten out as the stent is deployed. This helps prevent posterior dives, Dr. Shah said.

Editors’ note: Dr. Shah has financial interests with a variety of ophthalmic companies.

Crandall Lecture

This year’s Crandall Lecture was given by James Davison, MD, Marshalltown, Iowa, who covered some of the history of phaco and IOLs. Dr. Davison began by discussing his career perspective and how he first came to practice in Marshalltown, thinking he would be there for a few years—39 years later, he’s still in practice there.

Phaco and IOLs were new technologies when Dr. Davison first got into ophthalmology, and he called them an “actual paradigm shift.” It was revolutionary and many people were against them, he said.

At this time, there was a big bang, explosive pace of ideas, with symbiotic contributions by surgeons and industry R&D, he said.

Dr. Davison then went into the history of IOL development, beginning with Sir Harold Ridley, MD, and he also discussed the history of phaco, noting its invention by Charles Kelman, MD. Dr. Davison also mentioned a number of surgeons in the field that he worked with and those who made advancements in lenses and techniques. He noted some of his own contributions, including a variation to make different size lenses (either shorter or longer).

He concluded by saying “we’re some of the luckiest people in the world” and praising the specialty of ophthalmology.

Editors’ note: Dr. Davison has financial interests with Alcon.

‘Meeting Expectations in Refractive Cataract Surgery’

During another Friday morning session, Nicole Fram, MD, Los Angeles, California, discussed the unhappy cataract patient. The most common reasons for dissatisfaction are ocular surface disease, refractive error (from residual astigmatism, myopia, or toric rotation), and pseudophakic dysphotopsia.

She shared a number of steps to address these patients. First, she said you have to take a history and talk to the patient and figure out the onset of dissatisfaction. It’s important to know if the patient is having halo, glare, starbursts, or waxy vision. If PCO is present, Dr. Fram said to ask the patient if they were happy immediately after surgery. “Do not laser the capsule until you are sure the IOL will not be exchanged,” she said.

Her next step was examination, and she said to do a careful slit lamp exam and fundus evaluation.

Next, Dr. Fram highlighted diagnostics. Correct refractive error and reassess symptoms, she said, and perform a contact lens trial to separate the cornea from IOL. She also recommended a variety of tests, including topography/tomography, wavefront aberrometry, and macular OCT.

She then highlighted the treatment plan, saying that it’s important to support the patient and tell them that you will help. “Reassure the patient that they have a fixable problem,” Dr. Fram said. Achieve emmetropia prior to evaluating for exchange, she said, and knowing how to perform IOL repositioning or exchange safely is critical.

Editors’ note: Dr. Fram has financial interests with a variety of ophthalmic companies.

Key legislative and regulatory issues

Wrapping up Friday’s morning session, Nancey McCann, Fairfax, Virginia, ASCRS Director of Government Relations, gave an update on some of the key legislative and regulatory issues that may be impacting ophthalmology in 2020 and beyond.

Ms. McCann focused part of her presentation on the revalued cataract surgery codes, noting that the last time cataract code was revalued was around 2013 (typically every 5–6 years). Cataract surgery is usually under scrutiny because of the volume, she said.

She explained the ciliary body destruction code (66711) triggered the revaluation of the entire family of codes because it was done so more than 75% of the time in conjunction with cataract surgery.

A combination code with cataract surgery was developed and approved by CPT. ASCRS and AAO surveyed members about code 66984 and presented findings to the RUC, along with a proposal that emphasized the intensity of the procedure. The RUC recommended an updated work RVU value based on the proposal, and CMS finalized it in the 2020 final rule. ASCRS also provided resources to members to help understand the process and impetus for the reduction. The 2020 reimbursement under code 66984 is $557.

Another important topic Ms. McCann highlighted was E/M codes. The RUC revalued the codes and recommended significantly higher values, and CMS accepted those values, she said, emphasizing that the eye codes are not currently impacted, but CMS asked for comments in the proposed rule on whether they should be updated. ASCRS and AAO commented that the eye codes should be increase, but they were not increased, she added.

With revalued office visit codes, documentation is now focused on clinically relevant history and exam, Ms. McCann said. The visit level is determined by medical decision-making or time. Unfortunately, they did not increase the value of postoperative E/M codes in 10- and 90-day global, she said. Our argument, she added, is that “we just got revalued” with a confirmation that we perform three postop E/M visits.

Increasing the value of postoperative E/M visits in the global codes would nearly restore the cataract surgery value to its 2019 level. ASCRS and the surgical community will continue to advocate for the values to be increase before 2021 and for the elimination of add-on codes and the increase to eye codes, Ms. McCann said.

She also stressed that, due to budget neutrality of the fee schedule, increased E/M values will have a negative impact on surgical and procedural codes. The 2021 impact on ophthalmology of the final policy will be about –6.6%, she said, and “we are impacted more than any other specialty.” If the global codes are increased, it would be –2%, Ms. McCann added.

To pay for the increased E/M values, there will be a significant negative impact on the conversion factor, or CMS could make other across-the-board reductions in 2021, she said.

The impact of add-on codes is significant, Ms. McCann said. With withdrawal of the add-on, and no global code fix, the impact on ophthalmology would be –3.5%; but if the global codes are increased and the add-on code is withdrawn, there would be a 1.3% increase for ophthalmology.

ASCRS and the surgical community have many advocacy efforts to increase the E/M codes in the globals and to eliminate the add-on codes, including a possible lawsuit, advocating for legislative language in the May 22 Extenders bill, and a potential public relations campaign on the value of surgery.

During her presentation, Ms. McCann also highlighted some of the key MIPS changes for 2020. The MIPS performance threshold is now 45 points (up from 30 in 2019). The quality category is worth 45% of the final MIPS score, and the data completeness threshold was increased to 70% (from 60%). In the cost category (worth 15% of final MIPS score), CMS did not finalize the proposal to increase the weight in 2020 (as a result of advocacy from ASCRS), but cost must be weighted at 30% of the final MIPS score by performance year 2022.

She also mentioned the MIPS Value Pathways (MVPs), which are scheduled for implementation in 2021. ASCRS, as part of an AMA MIPS workgroup, developed a voluntary proposal to streamline MIPS reporting around specific conditions or procedures, giving credit across the four components. CMS would create MVPs for conditions or specialties and require clinicians to report, she said. However, the scoring is similar to the current MIPS program, with no cross-category credit, she said. ASCRS and the medical community are opposed to mandatory participation.

Ms. McCann also shared the details of the 2020 cataract episode measure. This measure is 66984 (no complex cataract). It includes 60 days preop and 90 days postop and excludes patients with major ocular comorbidities. It includes separately payable drugs, including one on pass-through (Omidria, Omeros). No other pass-through drugs are included in the 2020 measure. There are sub-groups for ASC vs. HOPD and unilateral vs. bilateral. You must have at least 10 attributed cases to be scored, she said. The measure includes preop testing, the surgeon’s professional fee, facility fee, anesthesia, and costs of any additional procedures billed separately from the global fee.

Editors’ note: Ms. McCann has no relevant financial interests.

EyeWorld Onsite is a digital publication of the American Society of Cataract and Refractive Surgery and the American Society of Ophthalmic Administrators.

Medical editors: Eric Donnenfeld, MD, chief medical editor; Rosa Braga-Mele, MD, cataract editor; Clara Chan, MD, cornea editor; Nathan Radcliffe, MD, glaucoma editor; Vance Thompson, MD, refractive editor

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