Mid-year changes aren’t often significant. This year, however, there are some things providers should know in two specific areas: the Quality Payment Program (QPP) and the proposed rule for the 2021 Medicare Physician Fee Schedule (MPFS).

Do any of these changes go into effect right away?

Yes. In fact, in the QPP 2021 arena, a couple of the changes are retroactive to January. One of the QPP changes affects those who file for QPP Quality measures via claims in the area of diabetes.

The claims-based filers should know that although CMS announced changes in codes for some diabetes measures in the Final Rule for 2020 MPFS and many doctors began to properly use them, CMS acknowledged in July that it never actually activated the new codes after mandating their use, so those practices and providers who actually reported the “unactivated” codes on their claims would be unable to get credit for the two affected measures. CMS’ July action to help providers was to suppress the scoring for those two diabetes measures for 2021 claims-based reporting.

Scoring for other types of reporting (“Registry” is the most common methodology in ophthalmology) is unaffected by this suppression and reporting of these measures will be scored normally. 

The two measures of note are:

• Measure 1: Diabetes: Hemoglobin A1c (HbA1c) Poor Control (less than 9%)- This is not common for eye providers to do, but some have used it.

• Measure 117: Diabetes: Eye Exam- This is a quite common measure for all types of eye-care providers.

Practices who report either of the above measures via claims won’t be given any score in them. If you reported the more common measure # 117, your denominator is reduced by 10 points (from the more normal 60 down to 50 if you had six quality measures). Additionally, CMS noted that those affected will not have to find an alternative measure due to the lateness in the year when CMS acknowledged its error. With fewer measures, though, there may be less room for error to hit the proper scores to avoid a penalty in 2023 (what you do in 2021 affects you two years later). More practices might need to select the hardship exception due to COVID-19, which is available to claim until December 31, 2021 at 8 PM Eastern time.

What is the other CMS change to QPP for 2021, and how might it affect my QPP score?

This important change relates to a CMS mid-year update to the Historical Benchmark files. These are the actual publicly-available scoring files that CMS uses to determine the deciles in which the Quality scores are given (providers are compared to others who have historically reported the same measure in a prior year). It has the potential to affect every provider, since all types of reporting (Claims, Registry, and Merit-based Incentive Payment System Clinical Quality Measures, or MIPS CQM) methods are included. Most eye doctors report via Registry and some via claims; not many do the MIPS CQM methodology.

On June 10, CMS reported that they had recalculated the deciles for the Historical Benchmark files. In no case did a score in any quality measure go “up a decile” so as to improve the score you might get. In all cases, a score on a measure you reported moved down a decile, so your achieved points go down as a result.

This can be a difficult area to understand, so here’s an example: Your score on a percentage basis might be 85 percent on a measure before the CMS update to the file, so this fell in the 5th decile when compared to everyone who reported that measure via that method. Now, that same 85 percent will be in the 4th decile—your max score just decreased a whole point. The effect of the loss of a single point doesn’t seem significant at first, but this loss is now magnified, since your score in every measure goes down a decile from the original level. This could mean your practice now gets six fewer total points in Quality-—and the maximum score was already only 60/60. 

Once again, providers might need to decide to take the hardship exception if they don’t achieve the minimum for penalty avoidance (it was 45 in 2020 but hit 60 in 2021).

What are the mid-year changes to 2021 CPT Category III codes?

As always, some Category III codes went into effect in July; we wrote about those in the “What’s New for 2021” Medicare Q & A in Review’s February 2021 issue. They’re unlikely to have coverage and payment at this time.

I’ve heard that some of the proposed payments for new surgery codes that go into effect in January 2022 are going to affect ophthalmology quite adversely. What are those?

Perhaps the two most important codes for the average eye surgeon to be aware of are new codes 669X1 and 669X2 (these “X codes” aren’t the real codes we’ll use in January, but rather a “placeholder” for now). We’ll know the real codes in a few months. These two codes are combination codes for cataract/IOL with an ab-interno insertion of aqueous drainage device without reservoir. 669X1 is for use with these minimally-invasive glaucoma surgery devices and a complex cataract/IOL; 669X2 is for these same MIGS but with “regular” cataract/IOL surgery. The code descriptors are quite long, but they’ll take the place of the current two-code pair we’re using in 2021 (with two separate payments), replacing them with a single code with cataract/IOL and applicable MIGS procedures (e.g., iStent and Hydrus are among the minimally-invasive glaucoma surgeries that fit here). 

In January 2022, you’ll only file for a single code. (669X2 applies in 2022 instead of what’s currently done in 2021: 66984 and 0191T)

Payments for the new single code proposed by CMS are abysmally lower than the sum of the payments for the current two codes.

What can I do to alleviate the potential hit to my practice from these codes?

The Medicare Physician Fee Schedule Proposed Rule always causes a great deal of consternation, and some years are worse than others for our specialty. If you’re not already doing these procedures and don’t plan to, the change won’t affect you at all.

Your professional societies are well aware of the proposed changes in reimbursement and how they might adversely affect both providers and facilities. Make your opinion known to your representatives and keep track of developments here. It’s very likely—but not guaranteed—that the big hit proposed will be mitigated a bit, so perhaps the sky is not falling. If you don’t speak up, however, you’ll have to accept the final result. It might be prudent to revisit your current MIGS surgery choices. It’s better to be prepared and ready for the change if you really do have options. 

As the famous motto goes: Be prepared.

Mr. Larson is a senior consultant at the Corcoran Consulting Group and is based in Tucson, Arizona. He can be reached at plarson@corcoranccg.com.