Q: Will Medicare patients face increased premiums in 2006?
A: Medicare Part B monthly premiums increase from $78.20 to $88.50 in January. This 13-percent increase helps to prevent a further decline in the Part B trust fund assets. Medicare regulations mandate that the monthly premium for Medicare Part B be sufficient to cover 25 percent of program costs, including the costs of maintaining a reserve against unexpected spending increases.
The Part B deductible will increase from $110 to $124. The Medicare Modernization Act stipulates that the Part B deductible be indexed to the increase in the average cost of Part B services.
Although reimbursement for many specific services in ophthalmology has decreased in recent years, overall payments for ophthalmic services rose 5 percent from 2003 to 2004. As a specialty, ophthalmology received $3.8 billion of the $79 billion paid for Part B services in 2004.
Q: Are ASC reimbursement rates still frozen?
A: CMS Transmittal 690 confirms that reimbursement rates for ambulatory surgery centers will not change in 2006. ASC rate changes normally occur on October 1, unlike the physician fee schedule, which changes on the calendar year.
The 2003 Medicare Modernization Act required a rollback of ASC payments on April 1, 2004, and freezes payment changes through 2009. In the meantime, CMS will reassess the cost to provide services in an ASC compared to a hospital outpatient department (HOPD).
A bill introduced on October 7, 2005 to reform the ASC payment system would link ASC payment rates to those of an HOPD. It suggests that ASCs be paid at 75 percent of the HOPD fee schedule, and revises the list of approved ASC procedures. The new system would take time to phase in, and we're not likely to see any change in 2006.
Q: Are there any changes to ophthalmic screening services for Medicare beneficiaries?
A: The proposed 2006 Medicare Physician Fee Schedule adds Hispanics age 65 and older to the eligibility list for annual glaucoma screening. Medicare beneficiaries with diabetes, a family history of glaucoma and African Americans age 50 and older are already considered at high risk and eligible for a yearly glaucoma screening exam. The utilization of the HCPCS code for glaucoma screening (G0117) is extremely low, with just 1,840 CMS claims paid in 2003. This number may not accurately reflect the number of patients seen for glaucoma or ocular hypertension, since some patients present with multiple complaints, justifying a different type of exam.
Q: Are any changes expected with the evaluation and management codes in 2006?
A: The confirmatory consultations (99271-99275), used when the patient seeks a second opinion, will reportedly be eliminated. The removal of these lightly utilized codes probably will not create large concerns. We also expect changes to the nursing home E&M visit codes, but the specifics are not yet available.
Q: Are there any new ICD-9 diagnosis codes pertinent to ophthalmology?
A: October's update of ICD-9 codes contained a series of new diagnosis codes to describe diabetic ocular disease. Published in the May 4, 2005 Federal Register, these new codes took effect on October 1, 2005.
New codes pertinent to ophthalmology are: 362.03 nonproliferative diabetic retinopathy NOS; 362.04 mild nonproliferative diabetic retinopathy; 362.05 moderate nonproliferative diabetic retinopathy; 362.06 severe nonproliferative diabetic retinopathy; and 362.07 diabetic macular edema. Stratifying the severity of nonproliferative DR with these new codes should improve the quality of claims processing, enhance the precision of the medical record and aid in the government's ability to monitor disease regression and progression.
Q: Will there be any new HCPCS codes associated with drugs or supplies?
A: We expect to see an HCPCS code (L8609) published for AlphaCor, a keratoprosthesis made of a biocompatible, flexible, hydrogel material (PHEMA) similar to a soft contact lens. It is intended for use in adults with a corneal opacity that is not suitable for standard penetrating keratoplasty with donor tissue, where donor tissue has been declined, or where adjunctive measures required to prevent graft rejection are medically contraindicated.
In 2005, a "not otherwise classified" HCPCS code, J3490, identified the supply of Macugen. A unique HCPCS code, J2503, takes effect on January 1, 2006 to describe this supply. The FDA approved Macugen (pegaptanib sodium) for treatment of all forms of neovascular macular degeneration. Macugen is administered via intravitreal injection, either in a physician's office or OR setting.
Q: Are there any new modifiers to append to claims?
A: Modifiers QB and QU will be replaced with AQ. This modifier will be used to report physician services provided in a Health Professional Shortage Area. The use of one modifier replaces the need to designate whether the service is provided in an urban or rural HPSA.
Ms. McCune is vice president of the Corcoran Consulting Group. Contact her at DMcCune@corcoranccg.com.
