Eyeworld

10 | EYEWORLD | OCTOBER 2019 ASCRS NEWS Q&A between Nick Mamalis, MD, and Parag Parekh, MD Dr. Mamalis: Can you provide an overview of the RUC process and how codes are revalued? Dr. Parekh: Since the early 1990s, Medicare physician reimbursement has been determined through the resource-based relative value scale (RBRVS), which assigns value to all physician services based on three components: work, practice expense, and malpractice values. In this budget-neutral system, each of these compo- nents for a given service are assigned specific relative value units (RVUs) that are adjusted for geographic price differences if necessary, added together, and multiplied by the conver- sion factor to arrive at a dollar figure, which is what Medicare reimburses the physician. Since the fee schedule is budget neutral, meaning that changes in RVUs cannot cause expenditures to increase or decrease more than $20 million, CMS also makes adjustments to the conversion factor to maintain budget neutrality. Work RVUs are based on the time and intensity required to furnish the service and determined through the RUC process. The RUC is made up of physicians from 31 dif- ferent specialties and is charged with regularly reviewing and updating the values for more than 10,000 different physician services. When a code is identified for review by the RUC, medical societies whose members perform the service are tasked with surveying their members on the work required for the service and devel- oping a recommendation to the RUC based on the survey results. Because the value must be relative to all other services, the presenters must crosswalk to other services with similar time and intensity to justify their requested value. The RUC deliberates on the data presented and makes a recommendation to the Centers for Medicare and Medicaid Services (CMS). CMS can either accept the RUC recommendation or make further refinements to the value. Cataract surgery code valuations About the doctors Nick Mamalis, MD ASCRS President Parag Parekh, MD ASCRS Government Relations Committee Chair Since the release of the 2020 Medicare Physician Fee Schedule proposed rule that included revised cataract surgery values, ophthalmologists have been asking questions about how and why the revaluation came to be and what the impact will be on their practices. ASCRS Government Relations Committee Chair Parag Parekh, MD, has represented our society at the American Medical Association's Relative Value Update Commit- tee (RUC) for the past several years. Subspecialty societies join with the American Academy of Ophthalmology (AAO) to defend the value of ophthalmic services; for example, the American Society of Retina Specialists worked with AAO on the retina injection codes, and ASCRS worked with AAO to defend cataract codes. As our RUC representative, Dr. Parekh has a front-row seat to see how these decisions get made and what ASCRS does to advocate for our members. —Nick Mamalis, ASCRS President Dr. Mamalis: Why was cataract surgery target- ed for review? Dr. Parekh: All services must be periodically reviewed, usually every 5 to 7 years. A subcom- mittee of the RUC, the Relativity Assessment Workgroup (RAW), uses various criteria to prioritize review, such as codes that are poten- tially overvalued or have significant changes in utilization. In our case, data showed that when a low volume code, 66711 ciliary body destruc- tion, was billed, more than 75% of the time it was in conjunction with cataract surgery. This necessitated a new CPT code that combined the two services and a revaluation of all the codes in that "family," including cataract surgery. Dr. Mamalis: Can you describe ASCRS's and AAO's survey process and recommendation? Dr. Parekh: ASCRS and AAO conducted an anonymous random survey of about 1,500 of our members and received 93 responses, which exceeded the minimum of 75 responses neces- sary for codes of this volume. The survey fo- cused on all the work associated with the proce- dure—the pre-, intra- and post-service, as well as the E/M office visits included in the 90-day global postoperative period. The survey found that since the previous revaluation 6 years ago, the pre- and post-service time decreased by 4 minutes, the intra-service time decreased by 1 minute, and there were three postoperative vis- its furnished, down from the current four visits. Survey participants were significantly uniform in their responses. The cataract procedure's intensity has always been an integral factor in determining the value. Intensity includes mental effort and judgement, technical skill, physical stress, and psychological stress. Because the surgeon must be inside the eye for the entire procedure, cataract surgery has a higher intensity value than almost any other surgery, including neuro- and cardiac surgery. So while the RUC recommend- ed a significant cut because of the lost continued on page 12

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