Q: I heard there were new CPT codes for ophthalmology. Are these for new procedures?
A: Ophthalmology gets five new codes this year, not the usual one or two. Typically, the number of codes the Academy of Ophthalmology requests is the number of new codes we receive.
The new codes are a mixed bag. There are codes for relatively new corneal surface procedures, a lid code for a procedure that has been around for a while, and a code for pachymetry that replaces a temporary code that has also been available for some time.
The chart below shows the new codes. CPT codes 65780 to 65782 and 68371 will be primarily used by cornea specialists to correct surface abnormalities.
• 65780 is the simplest of these techniques, for ocular surface reconstruction using amniotic membrane.
• 65781 is for grafting stem cell tissue as an allograft, and 65782 is for using limbal conjunctival tissue taken from the patient, usually using the fellow eye.
Both include obtaining the donor tissue.
• 68371 is for obtaining graft material from a living donor other than the patient.
|New CPT Code||2004 Office Pay||2004 Facility Pay ((hospital only, awaiting ASC approval)|
|65780||Ocular surface reconstruction||n/a||$723.06|
|65781||Limbal stem cell allograft||n/a||$1,102.15|
|65782||Limbal conjunctival autograft||n/a||$950.37|
|68371||Harvesting conjunctival allograft||n/a||$341.85|
|67912||Correction of lagophthalmos||$931.75||$395.61|
|Source: American Academy of Ophthalmology|
The last two codes will be more useful for general ophthalmology practices.
• 67912 is not a new procedure, but it is a new code. It is for patients with a facial nerve paresis that prevents them from closing their eye, causing the cornea to be exposed. A tiny gold weight is embedded under the skin of the upper lid to assist with lid closure. This procedure has been around for a while, and the AAO's Health Policy Committee is pleased that it finally has its own CPT code.
• 76514 is for ultrasonic pachymetry, which has become an important diagnostic test to determine corneal thickness in patients with glaucoma as well as in those with corneal disease. We are happy to get this CPT code, but not happy with the payment proposed by CMS. We thought that the value would be higher. When CMS publishes the final fee in the Federal Register, it doesn't break down how the value was determined. We have requested access to CMS data, and hope to convince the agency to revisit the issue.
Q: How are new CPT codes established?
A: The process starts with the AMA CPT Committee, because the AMA holds the copyright to the CPT codes. An organization or individual provider (anyone can request a new CPT code) must make application to the committee.
There's an extensive 10-page form to fill out, in which the applicant must explain why the procedure is being performed, indicate if it's a new procedure or replacing a current procedure for which there is already a code, whether there is peer-reviewed literature to support it, and so on. The AMA's CPT panel reviews the application, and usually will approve a carefully presented request.
At this point, the physician's work has to be valued by the Relative Value Update Committee of the AMA. The AAO surveys 100 to 125 ophthalmologists, asking them to rate the work involved in terms of time, skill, effort and risk. This is a relative value scale, so we ask them to rate it in comparison to other procedures that have a value, such as cataract surgery.
After we collate the results, AAO presents the value to the RUC, which makes the final determination of the physician work value and forwards that recommendation to CMS. Most of the time, CMS accepts the RUC recommendation.
Physician work is then combined with malpractice costs and practice expenses to determine the final payment using this formula:
Practice expense + malpractice cost + physician work = total relative value units (RVUs).
Generally, physician work makes up about 50 percent of the total RVUs, while practice expense and malpractice cost together make up the remainder.
Q: What's the difference between "office pay" and "facility pay"?
A: Office pay means the fee paid to the ophthalmologist if he/she performs the procedure in the office. Facility pay means the fee paid to the MD if the procedure is performed in a facility other than the office. Generally the office pay is higher because the physician will use more of his/her office resources than if the procedure is performed in a facility. The grafting procedures are only valued for a facility setting because of their complexity. The lid procedure has values for both locations. Pachymetry has only an office value.
Dr. Kamenetzky, a general ophthalmologist in St. Louis, is the AAO RUC Advisor and serves on the AAO Health Policy Committee.