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Show Elimination of Consult Codes in Neuro-Ophthalmology: Another Blow To Our Subspecialty? There are threats to the practice of neuro-ophthal-mology from many directions. These include lack of recognition in academic centers (1), lack of reim-bursement for complex neuro-ophthalmic problems (2), and lack of procedures that provide income for practitioners (3). Now we have another threat-the loss of consultation codes from the Centers for Medicare and Medicaid Services (CMS). Yet neuro-ophthalmology is a consultative sub-specialty- patients do not come to us except on another physician's request for consultation. How did this situation arise? CMS proposed discontinuing consultation codes in July 2009. The reason for the proposal was that con-sultations were costing Medicare/Medicaid large amounts of money and there was evidence that consultation codes were frequently used incorrectly by physicians not knowing the difference between a referral (transferring the care from one physician to another) and a consultation (rendering an opinion about a condition and sending back to the re-questing physician). In October 2009, CMS published the 2010 guidelines for payment (http://edocket. access.gpo.gov/2009/pdf/E9-26502.pdf) that eliminated this code. The rationale cited in the Federal Register was based on a review by the Office of the Inspector General entitled ‘‘Consultations in Medicare: Coding and Re-imbursement'' (4). CMS stated that elimination of the codes would be budget neutral as the work relative value units for new and established office visits would be in-creased. To quote, ‘‘We believe that the rationale for a differential payment for a consultation service is no longer supported because documentation requirements are now similar across all E/M services.'' The long-term repercussion of this action is unknown. Neurology Today reported that a call to several of the private payers (Cigna, Aetna, UnitedHealthCare) revealed that they were studying whether to follow suit (5). What is a neuro-ophthalmologist to do? Undoubtedly, we will still be called on to render opinions about complex clinical cases. The leadership of the North American Neuro-Ophthal-mology Society (NANOS) recognized that this CMS decision might have deleterious effects on the ability of neuro-oph-thalmologists to maintain their income and to attract trainees. So, the organization took action.NANOS sent a letter to CMS outlining reasons that this proposal would impact our discipline and impede patients' long-term ability to access neuro-ophthalmologists. NANOS helped to form a coalition that included societies representing endocrinology, infectious disease, rheumatology, and several neurologic subspecialties. Representing over 30,000 physicians, this coalition solicited from its members' letters to their legislators and to CMS protesting the elimination of consultation payments. NANOS leadership participated in the Association of American Medical Colleges (AAMC) conference calls and contacted the Ameri-canMedical Association. NANOS invited several other groups to participate in this coalition's efforts, and other subspecialty societies have sounded the alarm. NANOS surveyed its U.S. members to gather ideas on how to reduce the financial impact on their practices and engaged the services of Mr. Steven Sadowski, a principal of ECG Consultants-a well-respected na-tional firm who frequently serves as a consultant to the AAMC. Mr. Sadowski reviewed the membership survey responses and modeled the practice economics of 7 vol-unteers representing different kinds of practices (surgical vs nonsurgical, neurology vs ophthalmology, academic vs private practice). At the 2010 Annual NANOS meeting, Mr. Sadowski explained the history behind the CMS method of physician payment and focused on resource-based relative value scale with regional adjustments. From the session on ‘‘How to Earn Money in the Post-Consult World'' came the fol-lowing suggestions: ‘‘Run the numbers'' of Medicare/Medicaid patients; evaluate your practice mix and what the result of this ruling will have on your practice. Use Medicare/Medicaid outpatient codes as new (99201-99205) or follow-up (established 99211- 99215) or, where appropriate, as new or follow-up eye exams (92002, 92004, and 92012 and 92014) as we cannot use consultation codes. Analyze your practice for income decline and ways to improve efficiency and reduce costs. Find ways to maximize revenue: remember that CMS pays an extra 2% for physicians who use e-prescribing. If you use time codes, patient education is a factor that will be considered; documenting education time with our patients will be more important. Monitor whether Section Editor: Kathleen B. Digre, MD 210 Frohman and Digre: J Neuro-Ophthalmol 2010; 30: 210-211 Neuro-Ophthalmology News Copyright © North American Neuro-ophthalmology Society.Unauthorized reproduction of this article is prohibited. any of your private payers have adopted this new system. While the full impact of the CMS decision to eliminate consult codes is still uncertain, rest assured that NANOS leadership continues to serve its members by advocating for neuro-ophthalmology. Larry Frohman, MD UMDNJ-New Jersey Medical School Newark, New Jersey Kathleen Digre, MD University of Utah School of Medicine Salt Lake City, Utah REFERENCES 1. Frohman LP. How can we assure that neuro-ophthalmology will survive? Ophthalmology. 2005;112:741-743. 2. Fuhrmans, V. Medical specialties hit by a growing pay gap. Wall Street Journal. May 5, 2008:page 1. 3. Frohman LP. The human resource crisis in neuro-ophthalmology. J Neuroophthalmol. 2008 Sep;28(3):231-234. 4. Federal Register/Vol. 74, No. 226/Wednesday, November 25, 2009/Rules and Regulations. Available at: http:// edocket.access.gpo.gov/2009/pdf/E9-26502.pdf. Accessed May 7, 2010. 5. Butcher L. Fallout from new Medicare policy on consultation codes continues. Neurol Today. January 7, 2010;10:20. 6. Lawrence P. Martinelli, Daniel P. McQuillen, Jason A. Scull devaluing a specialty: the Centers for Medicare and Medicaid Services proposal to eliminate consultation codes. Clin Infect Dis. 2009;49:995-996. NANOS 36th Annual Meeting: Tucson, Arizona, March 7-11, 2010 The Starr Pass Marriott Resort in Tucson, Arizona, was the site of the 36th Annual Meeting of the North American Neuro-ophthalmology Society (NANOS) on March 7-11, 2010. The meeting drew a record of 393 attendees with 43 from outside of North America. The Walsh Meeting kicked off the week, and Brian Younge, MD, and his colleagues of the Mayo Clinic were the hosts. The neuro-pathologist, Caterina Giannini MD, PhD, and neuro-radiologist, Patrick H. Luetmer, MD, of the Mayo Clinic provided insightful commentary to the challenging and interesting cases. The best Walsh paper was ‘‘A Bitter-Sweet Diagnosis'' by Rebecca Stacy, MD, from Massachusetts Eye and Ear Infirmary. The symposia this year included understanding the melanopsin pathway and its contributions to the pupillary function, sleep, and photophobia. ‘‘Controversies in Neuro-ophthalmology'' highlighted different opinions in the work-up of anisocoria, whether multiple sclerosis and neuromyelitis optica are the same disorder, and treatment options for hereditary optic neuropathies. The ‘‘Neuro-ophthalmology of Cancer'' highlighted the current treat-ment of neoplasms that involve the visual pathways as well as paraneoplastic immunology and syndromes. ‘‘OCT in Neuro-ophthalmology Practice'' and ‘‘Thyroid Eye Dis-ease'' rounded out the symposia. The 2010 Dan Jacobson lecturer, Deborah Friedman, MD, MPH, reviewed a variety of diagnostic and therapeutic issues regarding idiopathic intracranial hypertension in ‘‘IIH with Dan and Beyond.'' Platforms and Poster sessions highlighted outstanding research being done by medical students, residents, fellows, and members of NANOS. The best presentation by a medical student was Jonathan Frandsen (M2) from the University of Utah, for his paper: Macular cartenoids in patients with photophobia. Best presentation by a resident was Patrick Yu-Wai- Man, MD, from the Mitochondrial Research Group, Newcastle University, United Kingdom. His presentation was ‘‘Multi-system neurological disease is common in pa-tients with OPA1 mutations.'' The best presentation by a fellow was Robert Avery, DO, from The Children's Hospital of Philadelphia. His presentation was entitled: ‘‘Reference range of cerebrospinal fluid opening pressure in children.'' NANOS honored Jonathan Trobe, MD, at the banquet for his excellent service as the third editor of the Journal of Neuro-ophthalmology-2001-2009. NANOS awarded Larry Frohman, MD, the Distin-guished Service Award, the organization's highest honor. Dr. Frohman has been on the board for 14 years. He has served many positions including president-elect, president, and chair of the board. He is currently the NANOS treasurer. In giving the award, Dr. Deborah Friedman noted that besides all of the positions he has held for NANOS, Dr. Frohman created the Walsh Compen-dium in 1994, started the NANOS slide exchange, championed practice issues in neuro-ophthalmology, and secured grant funding for the Neuro-ophthalmology Virtual Education Library. Janel Fick, the administrative director from L & L Management Services, Minneapolis, Minnesota, made certain of a well-run meeting and fun-filled social events. Neuro-Ophthalmology News Frohman and Digre: J Neuro-Ophthalmol 2010; 30: 210-211 211 Copyright © North American Neuro-ophthalmology Society.Unauthorized reproduction of this article is prohibited. |
