In November 2022, CMS released its 2023 Medicare Physician Fee Schedule (MPFS) that included a projected 1% decrease in reimbursement for ophthalmologists and optometrists. That sounded manageable, but when we looked a little further, we found threatened cuts of 4.6% for the Medicare conversion factor, 2% for a full year of sequestration, and 4% for PAYGO due to the Budget Enforcement Act. Then, at the end of December, President Biden signed the $1.7 trillion omnibus budget bill, the Consolidated Appropriations Act of 2023, that relieved some, but not all, of the financial stress. PAYGO was postponed for 2 years (2023 and 2024) and Congress added a 2.5% positive adjustment to Medicare.

Although lobbyists for organized medicine had hoped for a better result, there is a sense of relief that dramatic cuts were averted. In early January, CMS recalculated the allowed amounts for the MPFS. Based on available information at the time of this writing, Table 1 summarizes the changes from 2022. CMS revised the relative value units (RVUs) for a few procedures, notably canaloplasty. Payment rates for ambulatory surgery centers and hospital outpatient departments increased 3.8% over the prior year.

Nonopioid Pain Management Drugs

At the beginning of 2022, Omidria (J1097; Rayner) became the first ophthalmic drug used in surgery to transition from CMS’s pass-through payment status to separate ASC payment under CMS’s nonopioid pain management surgical supply policy. The policy continues in 2023 for Omidria, and Dextenza (J1096; Ocular Therpeutics) follows the same pathway. However, Dexycu (J1095; EyePoint Pharmaceuticals), which lost pass-through payment status on December 31, 2022, did not qualify as a nonopioid pain management surgical supply by virtue of its package label and will no longer be eligible for separate payment. In the hospital outpatient department, the reimbursement for these 3 drugs is part of the facility fee, not separate.

CPT Code Changes

In January 2021, AMA dramatically revised the criteria for selection of the level of service for outpatient evaluation and management (E/M) services. In January 2023, the new criteria were extended to inpatient E/M services. Two different methods are available for code selection: medical decision making and physician time spent. Medical decision making is based on problems, data, and management. The result is straightforward, low, moderate, or high medical decision making in ascending order. Refer to the 2023 CPT codebook for more information.

A new Category III code effective July 1, 2022, is 0730T, “Trabeculotomy by laser, including optical coherence tomography guidance.” The new code appears in the 2023 CPT manual in the section on Category III codes.

CPT codes 66174 and 66175 were revised with the addition of a parenthetical: “e.g., canaloplasty.” Code 66174 is for “Transluminal dilation of aqueous outflow canal (e.g., canaloplasty); without retention of device or stent” and 66175 is for “with retention of device or stent.” Although there were many other changes in CPT and HCPCS, these are the relevant ones for glaucoma surgeons.

Medicare Error Rate

The law requires the Department of Health & Human Services to provide an annual report to Congress on errors within Part B Medicare. The most recent report for the Comprehensive Error Rate Testing (CERT) program is the 2021 Medicare Fee-For-Service Supplemental Improper Payment Data.¹ Among all specialties, ophthalmology and optometry can be proud of the accuracy of their claims for reimbursement and low error rates. In the most recent report, the error rate for ophthalmology was 1.9%. Optometry didn’t do as well, but their error rate of 6.4% was still lower than the error rate for all specialties of 8.5%.¹ This report also contained information on the error rate for cataract surgery, which was 12.7%. Because some minimally invasive glaucoma surgery is performed simultaneously with cataract surgery, we anticipate higher scrutiny of these combined procedures.

During the COVID-19 public health emergency, CMS contractors and other third-party payers reduced the amount of postpayment reviews and other scrutiny of providers. As COVID constraints relaxed, there has been a resurgence of activity related to compliance. A new line of inquiry and possible criticism relates to items and services that may not be “reasonable and necessary” and are consequently not covered. This differs from the usual critique that the service was not documented, not performed, or not coded properly. Instead, the Medicare contractor argues that the service did not satisfy the following criteria in the Medicare Program Integrity Manual:²

• Safe and effective
• Not experimental or investigational
• Appropriate for Medicare patients, including the duration and frequency that is considered appropriate for the item or service, in terms of whether it meets the following criteria:
  1. Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition or to improve the function of a malformed body member.
  2. Furnished in a setting appropriate to the patient’s medical needs and condition.
  3. Ordered and furnished by qualified personnel.
  4. Meets, but does not exceed, the patient’s medical need; and
  5. Is at least as beneficial as an existing and available medically appropriate alternative.

To justify repayment, the Medicare contractor stipulates that the service exceeded the patient’s medical needs and that the physician should have tried something else first. For example, in the context of treatment of open-angle glaucoma, either medication or laser trabeculoplasty is usually indicated before an invasive surgical procedure such as MIGS.

Growth of Medicare Advantage

Among the most important announcements of the year, we learned that 28.4 million Medicare beneficiaries enrolled in Medicare Advantage in 2022.³ This represents 48% of the 58.6 million eligible beneficiaries. The Congressional Budget Office estimates that enrollment will rise to about 61% of eligible beneficiaries by 2032. This strategic shift means that private contractors, such as UnitedHealthcare, will soon be responsible for more beneficiaries than CMS.

Conclusion

For 2023, the last-minute actions of Congress once again aided the Medicare program and mostly avoided large threatening cuts to physician reimbursement. With the exception of a few glaucoma procedures, Medicare reimbursement for physicians does not change much in 2023 and it improves significantly for ASCs. Medicare error rates increased in the most recent report to Congress and the amount of postpayment scrutiny rose as COVID restrictions relaxed and Medicare contractors returned to work. New criticism founded on allegations of unnecessary services increased the risk of an overpayment determination. Of note, cataract surgery garnered a lot of unwanted attention in 2022, which probably touches combined procedures with MIGS going forward. Lastly, the continued growth of Medicare Advantage signals a strategic shift, because most beneficiaries will be covered by a health plan governed by a for-profit entity.

Although Medicare Advantage Organizations contract with CMS to serve beneficiaries, they have considerable latitude to change payment rates, require preauthorization for procedures, use different coverage criteria for services, and administer claims processing differently. Physicians and providers will need to adapt to Medicare Advantage Organization processes and priorities. GP

Kevin J. Corcoran, COE, CPC, CPMA, FNAO, is president of Corcoran Consulting Group in San Bernardino, California.

References

1. US Department of Health & Human Services. 2021 Medicare fee-for-service supplemental improper payment data. Accessed January 24, 2023. https://www.cms.gov/files/document/2021-medicare-fee-service-supplemental-improper-payment-data.pdf-0
2. MPIM Chapter 13 §13.5.4 Reasonable and Necessary Accessed January 24, 2023. https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/pim83c13.pdf
3. Kaiser Family Foundation. Medicare Advantage. Accessed January 24, 2023. https://www.kff.org/medicare/issue-brief/medicare-advantage-in-2022-enrollment-update-and-key-trends/