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New Physician Fee Schedule Proposed

CMS Proposes New Physician Fee Schedule


The Centers for Medicare & Medicaid Services (CMS) has released its proposed physician fee schedule for 2020. Here are the highlights, based on the Academy's early analysis. Because this is a proposed rule, the Academy will work with CMS over the next few months to ensure a final version that is fair to ophthalmologists.

Academy, ASCRS Secure Equitable Cataract Reimbursements

The Academy partnered with the American Society of Cataract and Refractive Surgery in an exhaustive effort to retain reasonable cataract reimbursement for our profession.

CMS today agreed to the rate that the American Medical Association's Relative Value Scale Update Committee (RUC) submitted. Although this is a decrease, the rate is equitable relative to payments of other physician services of similar time and intensity. It is a recommendation to which the Academy and ASCRS agreed.

The RUC is a unique multispecialty committee dedicated to describing the resources required to provide physician services which CMS considers in developing Relative Value Units (RVUs).

In a process that began last year, the Academy and ASCRS negotiated with the RUC for a rate that is based on our members' survey data.

This extensive survey delivered to the RUC a robust data set culled from practicing ophthalmologists. It was combined with careful, sustained negotiations with the RUC. CMS accepted this recommendation for its proposed fee schedule for 2020.

The proposed cataract fees for 2020 are as follows:

Additionally, CMS is recommending Medicare Administrative Contractors set their own prices for new, combined cataract-and-ECP codes.

Despite the decrease, cataract surgery remains valued at the very top of the scale when compared with procedures of similar length. This is an acknowledgement of intraocular surgery's unique intensity and complexity.

Ophthalmoscopy Reimbursements

CMS is also making cuts to ophthalmoscopy fees. This is a very high-volume procedure, with very low-paying codes. Reimbursements for these codes will be even lower next year because now they will be bilateral instead of being billed on each eye. Physicians will no longer be paid for the initial ophthalmoscopy, only the extended procedure. Codes currently used to bill these procedures will be deleted.

The proposed ophthalmoscopy fees for 2020 are as follows:

The 2020 Conversion Factor

The proposed 2020 conversion factor is 36.0896, which would be up from 36.0391. There is a 0.14% budget-neutrality reduction.

The 2020 conversion factor for ambulatory surgical centers (documented today in a separate proposal) would be 47.827 for facilities that meet quality-reporting requirements, 46.895 for those that do not.

CMS' E/M Proposal

Last year, CMS permanently changed how E/M is reimbursed, collapsing the current five payment levels to just three. This change won't take place until 2021.

At this time, CMS is proposing to replace the impending changes to E/M with a plan put forward by the AMA on guidelines and descriptors in order to place more emphasis on the time required. The proposal would significantly increase the payment for these services in a budget-neutral manner that also negatively affects ophthalmology.

CMS is also proposing not applying these E/M adjustments to post-operative surgical visits that are built into ophthalmology's procedures.

Overall Effect

Because of the change to E/M and cataract and ophthalmoscopy codes, ophthalmology would experience one of the largest decreases among all medical specialties.

Quality Payment Program/MIPS Changes

The Merit-Based Incentive Payment System is getting harder. Physicians would need 45 points to pass, up from 30 points, thereby avoiding a 9% penalty. CMS also proposed increasing the cost category weight to 20%, up from 15%, along with fewer exclusions.

The Academy's IRIS Registry remains ophthalmologists' best tool for success in MIPS.

More Analysis Forthcoming

The Academy is reading and analyzing this massive, 1,704-page document (PDF, 7.6 MB). Make sure to visit the 2020 Medicare Fee Schedule page and read Washington Report Express in the coming weeks for more information on how this fee proposal will affect our profession.

For more information, contact Matt Daigle at


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