Reimbursement
How to Get Reimbursed in 2002
What you can expect from the new Medicare fee schedule.
BY KEVIN CORCORAN, C.O.E., F.N.A.O. AND DONNA MCCUNE, CCS-P, C.O.E., San Bernardino, Calif.

Every year we can expect more reimbursement changes and technological advances. And as always, the people at Medicare have modified the fee schedule, announced new codes and made new bundles. This year, they've also implemented a new benefit.

2002 Medicare fee schedule

The Centers for Medicare and Medicaid Services (CMS) published the "2002 Medicare Physician Fee Schedule" in the Federal Register, Vol. 66, No. 212, dated November 1, 2001. This schedule completes the 4-year transition period for implementing a new resource-based system to calculate Medicare reimbursement of physician services. The Balanced Budget Act required this change. The phase-in ended in 2001; the 2002 relative value units are entirely resource based.

The final rule includes a 5.4% reduction in the 2002 fee schedule. The conversion factor for calendar year 2002 is $36.1992 compared with $38.2581 in 2001. CMS made several changes to the relative value units assigned to services.

The net effect for optometry is mixed. Office visit reimbursement is relatively unchanged from 2001, with slight increases for the ophthalmologic codes 92004, 92014, 92002 and 92012. Reimbursement for consultations decreases slightly. Reimbursement for diagnostic tests increases significantly, except for extended ophthalmoscopy.

For example, extended visual field (92083) reimbursement increases about 15% and gonios-copy (92020) is up 28%. A decrease applies to some major surgeries. For instance, the reimbursement for cataract surgery with intraocular lens [IOL] (66984) decreases 10%. Co-management reimbursement will also decrease by 10%.

The proposed relative value units assigned to punctal occlusion with plugs (68761) published in August 2001 were rejected and revised in the final rule, resulting in a substantial decrease (33%) in 2002. Also, the supply of silicone plugs (A4263) is bundled with the procedure as of January 1, 2002 and will no longer receive separate reimbursement. Epilation of eyelashes (67820) was increased from $84.17 to $106.79 and foreign body removal (65222) was decreased from $192.44 to $64.07.

New codes in 2002

Another change involves optical coherence biometry (OCB). CPT code 92136, ophthalmic biometry by partial coherence interferometry with IOL power calculation, will be listed in the Special Ophthalmological Services section. This test uses the Zeiss Humphrey IOL Master to measure and calculate the IOL power without ultrasound. In 2001, many Medicare carriers reimbursed for this service with a miscellaneous code of 92499 or 66999. The addition of a unique CPT code should make claim processing easier.

Glaucoma screening

Starting January 1, 2002, the Benefits Improvements and Protection Act of 2000 (BIPA) provides for annual coverage for a glaucoma screening exam. Eligible beneficiaries are "individuals with diabetes mellitus, individuals with a family history of glaucoma and African-Americans age 50 and over." The exam includes a dilated eye exam with an intraocular pressure measurement and a direct ophthalmoscopy or a slit-lamp biomicroscopic exam. CMS has assigned HCPCS code G0117 (glaucoma screening for high-risk patients furnished by a physician) to this service and will reimburse approximately $52.

Physician supervision

Medicare liberalized the physician supervision requirements for some diagnostic tests, particularly visual fields and fundus photography. Under rules that took effect July 1, 2001, direct supervision is no longer required. General supervision applies, meaning that you need only order and interpret the tes, but don't have to be in the office suite when the test is performed.

Evaluation and management (E/M) guidelines

We probably won't see new guidelines implemented in 2002. The third revision of the E/M guidelines (1995 and 1997 revisions preceded this effort) was supposed to include clinical vignettes to help physicians link their decision making to a specific level of service. But physicians rejected the draft vignettes. So for now, the 1997 guidelines best serve your practices.

Stark II law

Published in January 2001, these regulations provide some clarification and relief from previously proposed rules. They were introduced in two phases; new phase one requirements are effective in 2002. The regulations created an exception for postcataract eyeglasses and contact lenses as a designated health service -- positive news for physician-owned optical dispensaries.

Medicare audit activity

The Office of the Inspector General (OIG) conducts annual audits of the CMS. It's estimated that Medicare made improper payments of $11.9 billion in 2000. The government has increased funding to investigate healthcare fraud. So OIG audit activity and Medicare Carrier audits continue to increase.

Consequently, physicians seek ways to avoid the administrative errors that can lead to a costly legal defense. Many consider compliance programs, which don't clear you fully but do make prosecution for fraud unlikely. In "Compliance Program Guidance for Individual and Small Group Physician Practices," the OIG says that although a program isn't mandatory, it's wise.

Prevent unpleasant surprises

At a minimum, consider a quality assurance program that includes chart reviews to ensure compliance with third-party payer rules and regulations and a review of practice financial activities. Monitoring, physician and staff training, and analysis keep you current on issues that the government scrutinizes.

Expect continued changes in reimbursement and areas that affect it, such as regulatory issues and technological advances. Stay current with these changes and get paid for your services -- and avoid legal trouble.

Ms. McCune is a senior consultant with Corcoran Consulting Group. You can reach her at 800-399-6565 or e-mail at DMcCune@CorcoranCCG.com.

Mr. Corcoran is president of Corcoran Consulting Group. You can reach him at (800) 399-6565 or at kcorcoran@CorcoranCCG.com.