Cataract surgery reimbursement may be cut by about 15 percent next year, according to the proposed rule changes to the 2020 Medicare physician fee schedule released in July by the Centers for Medicare and Medicaid Services.   

Non-complicated cataract surgery (66984) may see a larger cut in reimbursement than complex cataracts (66982). The proposed Work Relative Value Unit (RVU) for complex cataracts is 10.25, compared to the current Work RVU of 11.08, a $47 reduction. For non-complicated cataracts, the proposed Work RVU is 7.35, compared to the current 8.52, a $97 reduction.¹

After negotiations and efforts to retain reasonable reimbursement for cataract surgery, ASCRS and AAO agreed to the rate set by the AMA’s Relative Value Scale Update Committee (RUC), which is responsible for describing the resources required to provide physician services. CMS takes RUC into account when developing RVUs. ASCRS notes that though it is a decrease, the rate is “equitable relative to payments of other physician services of similar time and intensity.”¹

“We’re disappointed in the value that we got, but we’re pleased it didn’t go down further,” says Michael Repka, MD, MBA, the vice chair for clinical practice at the Wilmer Eye Institute and the medical director for Governmental Affairs of AAO.

Reimbursement for cataract surgery has been progressively decreasing because ophthalmologists have gotten so good at it, says Douglas Grayson, MD, FACS, in practice at Omni Eye Services in New York. “Technology improved,” he says. “Cataracts back in the 1990s used to be hour-long procedures, and now they can vary anywhere from five to ten minutes. So basically, they’re paying for the time that it takes to do the surgery with some small factor added in for the complexity.” 

Part of the decrease in valuation reflects the proposed rule’s budget neutrality. “If cataract surgery goes down, those dollars get redistributed to other services in medicine,” says Dr. Repka. “Oftentimes, those dollars end up in evaluation and management services, or the dollars go to primary care.”

The random sample survey of AAO and ASCRS members required for RUC code revaluation showed a one-minute reduction in time to perform 66984 and one less postop visit, which Nancy McCann, ASCRS director of Governmental Relations, says always equates to some kind of reduction.² ASCRS and AAO demonstrated to the RUC cataract surgery’s unique intensity to bring the reduction to 15 percent, as opposed to 50 percent.²

The proposed rule has a 60-day comment period. Ms. McCann says ASCRS will submit comments, but will support the recommended values along with the Academy. E/M values are also proposed to increase, a move both ASCRS and the surgical community oppose.¹ Ms. McCann hopes that if these increases are made they will be factored into cataract reimbursement, which may bring the reduction in 66984 to the $90 range.²

“The only way we’ve been able to keep up with progressive cuts over the years is by finding new sources or new ways to maximize reimbursement,” explains Dr. Grayson. “At the end of the day, some doctors will say it’s too bad and take less reimbursement and some will try to figure out ways around it.” 

Dr. Grayson anticipates increases in femto laser, multifocal lens and MIGS procedures such as iStent, Hydrus and Kahook goniotomy—glaucoma procedures done in conjunction with cataract surgery—to make up for the deficit.  

“Increased volume in cataract surgery is another concern, and they may audit more charts to make sure visual criteria are defined well enough and that patients truly need cataract surgery,” Dr. Grayson says. “Certainly, they’re going to look at MIGS more closely because that’s an expensive ticket item for Medicare and for the primary insurers, because not only do they have to pay for the surgical procedure, they also have to pay for the device.” Dr. Grayson notes that the iStent Inject device costs over a thousand dollars. 

Dr. Grayson also says that decreased reimbursement may cause surgeons to reevaluate their schedules. “If you’re not that great a surgeon, it might not be cost-effective to go to the OR and do five cataracts at a decreased reimbursement. You could actually do better in the office just seeing a bunch of patients.”

Finding ways to streamline services and improve office efficiency is another way doctors might make up the reimbursement decrease, says Dr. Repka. “I expect that doctors will diversify and add some other services. Just be very careful about not charging for add-on services to try to recoup revenues, because those may or may not be legal, depending upon how they’re framed and billed to the patient.

 “We could have done more poorly than we did, but it’s hard to spin a loss as a win, and I wouldn’t try to,” concludes Dr. Repka. “The good news is that this proposed rule did not have any other eye services that CMS considers possibly misvalued, which means we don’t have to defend anything next year. So that, at least, is a good thing.”

^{1. 2020 Medicare physician fee schedule (MPFS) proposed rule released. ASCRS. August 2019. http://ascrs.org/about-ascrs/news-about/2020-medicare-physician-fee-schedule-mpfs-proposed-rule-released}

^{2. McCann N. ASCRS special report: Key information about the 2020 Medicare physician fee schedule proposed rule. ASOA. August 2019. https://asoa.org/news/ascrs-special-report-key-information-about-2020-medicare-physician-fee-schedule-proposed-rule}

Iodine Safe vs. Viral Conjunctivitis
Researchers recently found that 5% povidone-iodine (PVP-I) used as a one-time treatment is safe and well-tolerated by patients with adenoviral conjunctivitis.

A double-masked trial included 56 participants randomized to a one-time administration of
PVP-I or preservative-free artificial tears. The team assessed visual acuity, and safety using corneal fluorescein staining, and tolerability using participant-rated overall ocular discomfort. 

In the PVP-I group, the study authors discovered that corneal staining increased immediately post-administration but returned to baseline levels by day one. They noted no change in visual acuity between baseline and day one in either group. In the povidone-iodine group, they also found no change in participant-rated overall discomfort immediately post-administration or on day one, compared with baseline. 

In the artificial tear group, on the other hand, they note that participant-rated overall discomfort was lower immediately post-administration but returned to baseline levels by day one. The investigators add that there was one adverse event in the povidone-iodine group within the first two days following drop administration that was unrelated to treatment.  REVIEW

^{Shorter E, Whiteside M, Harthan J, et al. Safety and tolerability of a one-time, in-office administration of 5% povidone-iodine in the treatment of adenoviral conjunctivitis: The Reducing Adenoviral Patient Infected Days (RAPID) study. Ocul Surf. August 8, 2019 [epub ahead of print].}