This has been an unprecedented year. Practices across the country have lost nearly a quarter of the year’s revenue due to the COVID-19 public health emergency, among other hardships. There is, however, another hurdle to face: CMS has finalized a policy that will cut reimbursement for surgical specialties, effective January 2021.
Under the proposed change, all E/M services will increase in value, and the conversion factor will decrease, in order to maintain budget neutrality. This will result in payment decreases for all other codes in the physician fee schedule, including postop visits.
Wilmer Eye Institute’s Michael Repka, MD, the AAO’s medical director for governmental affairs, says that surgery-heavy ophthalmic subspecialties will experience the most negative effects from these changes, as will those who don’t perform much E/M.
“In almost every surgical code, there are postop visits included,” he explains. “If you have a 10-day global period, you might have one postop visit, or if you have a 90-day global period, you might have three postop visits. Those have traditionally been valued at the same level as E/M service, so if you were to have a level-three visit within the postop period, you’d receive the work RVU payment and that payment would be based on the level-three E/M service. CMS has decided not to increase the work RVUs of each of these postop visits, so they won’t get the same increase that the E/M visits get.
“All surgical or procedural specialties will be affected,” he continues. “They’re going to get lower payments for level-three services than for free-standing E/M services, which are done in the office. This policy change is important because as much as a third of the value of surgery is in the postop visits. Not only do we have the conversion factor going down due to the E/M increases, but we’re also not getting the work value increases relative for the postop visits.
“A reduction of this magnitude in a normal year may be devastating,” he adds, “but following 2020, which has been a bad year, this may not allow practices the room to recover in 2021. That being said, Congress and HHS were incredibly quick in the spring and early summer with relief aid, and we’re very grateful for that action. It could have been much worse.”
The Academy, along with the American College of Surgeons, ASCRS and other groups, has launched a lobbying effort called the Surgical Care Coalition. It aims to tell policymakers why these changes are potentially harmful to surgical access. The Coalition asks for the following:
1. Waive budget neutrality.
2. Eliminate the add-on complexity code.
3. Value postop and E/M visits equally.
“It’s great that the E/M codes are paying more—they really needed to do that,” Dr. Repka says. “If budget neutrality is waived, all other code values will stay the same and E/M can increase. That’s five billion dollars; the add-on complexity code also affects the conversion factor and comes to about 1.8 billion dollars. Valuing postop visits equally to E/M visits will be a more equitable solution than the double hit CMS has proposed. However, all this requires payment and money.
“The final rule is due out—we’re told—in early December, which is about 30 days later than normal,” he continues. “This is a problem for our members because these changes have to be incorporated by EMRs, practice management software, EMR companies and insurance companies. There are always changes from CMS to incorporate every year to prepare the new fee schedule and other rules for January 1st, but this year we’ll have less than half the time we usually do. Rushing often leads to errors, and those could take months to fix.”
Dr. Repka says that despite ongoing legislative efforts, it’s very likely this policy change in some form will go into effect—but that doesn’t mean there’s nothing you can do. He recommends examining the new E/M descriptors to see where it’s advantageous to code outpatient visits with an E/M code, rather than with an Eye code.
“The E/M descriptors become very different in 2021,” he says. “You’ll choose your code level based entirely on medical decision-making. That includes the number of diagnoses you consider for the problem, the number of problems you manage, the amount of laboratory testing that has to be ordered and incorporated, the number of records that need to be reviewed and the risk of morbidity from the problems you’re managing. Taking a little time to learn the new codes, and particularly the steps in medical decision-making, will help you make the most advantageous choice.”
In addition, he recommends looking at the MPFS and your expenses. “Be sure that you’ll still be able to care for certain conditions,” he says. “Also keep tabs on what’s being published by medical organizations and CMS. There will be many rules changes. It may also be a good idea to take a course on how to code under the new evaluation-and-management system.” REVIEW