Since the MPFS was adjusted by Congress after our most recent column, many—but not all—of the largest hits to reimbursement were lessened. Here, we discuss a few new wrinkles related to the glaucoma MIGS surgery bundles and payments, and answer questions about how the No Surprises Act might affect practices in 2022.
Did any new January 2022 bundles or payment edits from the new glaucoma MIGS codes affect possible treatment options?
They did. The two new combination codes for cataract/IOL/MIGS, 66989 and 66991, received a mutually exclusive edit with the other cataract combination codes established a couple of years ago for cataract/IOL/endocyclophotocoagulation (66987 and 66988). Remember that there are two distinct codes in each of them because one of them is for “complex” cataract/IOL surgery done with the other surgery. The pairs of combination codes listed below are mutually exclusive with one another for 2022 Q1, so you can’t bill both on the same eye; one of these combination codes will go unpaid for both surgeon and facility. Importantly, an ABN or financial waiver can’t be used to ask the patient to accept financial responsibility for the bundled code. The mutually exclusive code pairs are:
- 66987 – 66989
- 66987 – 66991
- 66988 – 66989
- 66988 – 66991
- 66989 – 66991
This latest set of combination bundles only affects the unusual surgical combination procedure of cataract/IOL, endocyclophotocoagulation, and the concurrent
Hydrus or iStent device in a single eye on the same day. That combination is sometimes abbreviated “ICE.” The NCCI edits do seem to allow unbundling but, importantly, you would only do that if billing for one of each code on the same day in different eyes.
Fortunately, there are lots of alternatives surgeons can choose from in the MIGS space. As you might expect, there are some other MIGS coding considerations already in place and most didn’t change even if payment might be lower now.
What’s the purpose of the No Surprises Act?
The Act was put into place January 1, 2022 to help prevent most types of surprise medical bills patients often run into. CMS has a Provider resource page you can access to learn more about it.1 While the Act doesn’t apply in every situation, it will apply in many, such as when a patient gets care at an in-network hospital and an out-of-network (OON) provider that the patient wouldn’t have known about ahead of time delivers care. Since OON charges can be significantly larger, the surprise isn’t that the patient gets a bill, but that the bill they get and the cost-sharing they incur will be much larger. If you take call at the local hospital ER, you might be that OON provider to a patient’s private medical insurance, so you must accept the in-network payment provisions and can’t balance-bill.
When patients have no insurance (or when they wish not to use it), there are now separate protections related to giving a cost estimate before you deliver services.
Importantly, CMS notes that the Act doesn’t impact some Federal programs such as Medicare, Medi-caid, Indian Health Services, Veterans Administration or TRICARE, since other regulatory protections against high medical bills already exist. When the patient has those types of coverage, items like refractions, upgrades on premium intraocular lenses, cosmetic surgery and screening tests don’t fall under the provisions of the No Surprises Act because those services: 1) are being delivered to people with coverage under those Federal programs; and 2) there is written regulatory guidance on noncoverage that already exists for those services.
Of course, you want to still be transparent and inform the patient about the lack of coverage, the costs for those services and patient responsibility to pay in this situation.
When the Act does apply to me outside of the ER situation above, what else must I know?
Three main things are key. The first is knowing when the Act applies and when it doesn’t, as noted above.
Second, when the Act does apply, a good-faith estimate of your charges may need to be given to patients up front so they can consent to them. Since the Act allows patients to request this, it also seems clear to me that all offices should step up their pricing transparency even if the Act isn’t implicated; I’ll bet patients will ask more often as knowledge about their ability to do so spreads.
Third, the Act sets up a specific dispute resolution process that is more formal than one you might already have in place for arbitration. If a patient gets a bill that’s more than $400 over your good-faith estimate, they can use the Act’s dispute resolution process. As you might expect, you’re obligated to tell them about it in your good-faith estimate. (CMS also has a webpage with information on what that means.)2 Since the dispute will invariably involve your estimate, you should keep a copy of these documents, since the Centers for Medicare and Medicaid Services will ask for your copies of the estimate should dispute resolution begin.
The patient must exercise their rights in such cases within 120 days of receiving your bill, not the date you delivered the services. Though it’s not part of the Act, it’s apparent that getting your bills out promptly is now even more important than ever.
What if my state already has a similar No Surprise medical bill regulation? Which one takes precedence?
Your state-specific guidelines remain in play; the No Surprises Act provides a floor for consumer protections. CMS notes “as long as a state’s surprise billing law provides at least the same level of consumer protections against surprise bills and higher cost-sharing as does the No Surprises Act and its implementing regulations, the state law generally will apply ...[and] if your state has an All-payer Model Agreement or another state law that determines payment amounts to out-of-network providers and facilities for a service, the All-payer Model Agreement or other state law will generally determine your cost-sharing amount and the out-of-network payment rate.”3
1. CMS. No Surprises Act. Provider requirements and resources. https://www.cms.gov/nosurprises/policies-and-resources/provider-requirements-and-resources. Accessed February 2, 2022.
2. CMS. Providers: What to expect when a patient starts payment dispute resolution. https://www.cms.gov/nosurprises/providers-payment-resolution-with-patients.Accessed January 31, 2022.
3. CMS. Fact Sheet. No Surprises: Understand your rights against surprise medical bills. Jan 03, 2022. https://www.cms.gov/newsroom/fact-sheets/no-surprises-understand-your-rights-against-surprise-medical-bills. Accessed February 3, 2022.
Mr. Larson is a senior consultant at the Corcoran Consulting Group and is based in Tucson, Arizona. He can be reached at firstname.lastname@example.org.