Q: How does the delay in implementation of the 2003 Medicare Physician Fee Schedule (MPFS) affect Medicare claims?

Claims filed and processed for physician services before March 1, 2003 will be paid at the 2002 MPFS. Claims processed after March 1, 2003, regardless of the date of service, will be paid at the 2003 MPFS. Reconciliation will take place in July 2003 for the January and February claims processed and paid at the 2003 fee schedule that should have been paid at the 2002 fee schedule. This may require refunds for overpayments and is likely to be a headache for your practice.

The MPFS is usually published in early November, implemented on Jan. 1 and valid through Dec. 31. The delayed 2003 MPFS was published on Dec. 31, 2002 and implemented on March 1, 2003. Considerable debate about the methodology led to intensive lobbying to change the regulation, which would have reduced the conversion factor by 4.4 percent. A change to the practice expense component of the calculation resulted in an additional 1 percent average reduction for ophthalmology.

In late February, a new Omnibus Appropriations bill passed allowing for a 1.6-percent increase to the conversion factor. (This bill had no effect on the 1-percent practice expense reduction for ophthalmology.) The Feb. 28, 2003 Federal Register published the change, effective March 1, 2003. Fee schedule information sent to providers in January is inaccurate. Most carrier websites published the actual 2003 fee schedule on March 3 to allow for provider access.

The MPFS does not affect ASC payment rates. Facility fees for ASCs are adjusted annually, effective date Oct. 1 through Sept. 30. ASCs received a 3-percent increase on Oct. 1, 2002. This was sizeable, since typical facility reimbursement increases have been about 1 percent.

Q: Were additional coding changes for 2003 impacted by the fee schedule delay?

The 2003 CPT book contains a new add-on code for the use of an endoscope with specific ophthalmic surgeries. Physicians were unable to use this code until the implementation of the 2003 MPFS. CPT code 66990 Use of ophthalmic endoscope may only be used with codes 65820, 65875, 65920, 66985, 66986, 67038, 67039 and 67040. Add-on codes are never used alone. They do not require modifier -51 and reimbursement is at full value. The national 2003 MPFS for this add-on code is $83.50. The operative report should describe the use of the endoscope in conjunction with the primary procedure.

Here are additional coding changes for 2003 you may have overlooked, including code changes and deletions for some retinal procedures:

 • G0186 had been described as Destruction of localized lesion of choroids (i.e., choroidal neovascularization, photocoagulation, feeder vessel technique). This code was revised and the G0186 code is used only for feeder vessel therapy.

 • Destruction of macular drusen, photocoagulation, is coded with Category III code 0017T. 

 • G0185 Destruction of localized lesion of choroids (i.e., choroidal neovascularization, transpupillary thermotherapy) was deleted and replaced by Category III code 0016T. Payment for these services continues to be at the discretion of the payer. No relative value units exist for these codes.

The description for the removal of lesions is revised in the 2003 integumentary section of CPT. Excision of an eyelid lesion (114xx or 116xx) is now defined as the removal of the lesion including margins. Formerly, the excision only included the size of the lesion.

Q: What changes have been made by CMS regarding the appeals process?

These changes became effective Oct. 1, 2002:

1. Medicare beneficiaries have 120 days to file an appeal for a Part B service if the initial payment determination is dated Jan. 1, 2003 or later. If the initial determination date is earlier, they continue to have six months to file.

2. Physicians have 120 days to file an appeal for a Part B service if the initial payment determination is dated Oct. 1, 2002 or later. For those dated before then, you continue to have six months to file.

3. The appeals process gives you, suppliers and beneficiaries the right to appeal to an administrative law judge. The requirement for the amount in controversy (AIC) for a Part B hearing changed. If the initial determination is prior to Oct. 1, 2002, the AIC must be at least $500. If the initial determination is on or after Oct. 1, 2002, the AIC is $100. The AIC need not be a solitary claim; it may be a combination of claims that add up to $100.

Q: Why are some health insurers switching to HCPCS codes and eliminating codes they used previously?

The HIPAA Electronic Standards Transaction requires that payers now use Standard Code Sets, such as CPT, ICD-9 (diagnosis codes), and HCPCS (Health Care Procedure Coding System). There are several HCPCS codes describing ophthalmic services. They include:

 • S0620 Routine eye exam, new patient, including refraction;
 • S0621 Routine eye exam, established patient, including refraction;
 • S0630  Removal of suture by another physician;
 • S0800 LASIK;
 • S0810 Photorefractive keratectomy (PRK); and
 • S0820  Computerized corneal topography, unilateral.

Medicare does not recognize these codes. Reimbursement varies by commercial payers. 

Ms. McCune is a vice president for Corcoran Consulting Group. Contact her at 800-399-6565 or DmcCune@CorcoranCCG.com.