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.