Impact of the Elimination of Consultation Codes on Neuro-Ophthalmology in the United States

Perspective Impact of the Elimination of Consultation Codes on Neuro-Ophthalmology in the United States Prem S. Subramanian, MD, PhD, Larry P. Frohman, MD, Valérie Biousse, MD, for the Quality of Neuro-Ophthalmic Care Committee of the North American NeuroOphthalmology Society O phthalmologists, neurologists, and other specialist physicians rely on consultative care from neuroophthalmologists in the diagnosis and management of optic neuropathy, eye movement disorders, and other ophthalmic manifestations of systemic disease. These neuro-ophthalmic consultations are significantly more time consuming and complex than typical new patient encounters, involving the review of medical records and imaging studies from a number of providers, generation of a consultation report assisting in the coordination of care, as well as counseling patients regarding their disease. The additional effort required traditionally has been recognized through increased reimbursement and valuation of these services. In March 2006, the Office of the Inspector General deemed that throughout medicine, there was widespread inappropriate billing for consultative services; it was reported that 75% of consultations billed to Medicare in 2001 did not meet criteria for consultations, resulting in $1.1 billion of inappropriate payments (1). Subsequently, the Centers for Medicare and Medicaid Services (CMS) instituted a rule (Change Request 6,740) that took effect on January 1, 2010 and disallowed the submission of consultative current procedural terminology (CPT) codes for billing purposes in both inpatient and outpatient settings (2), resulting in a decrease in reimbursement (3). This action was predicted to have devastating consequences for neuro-ophthalmologists (4). Therefore, we analyzed recent (2014) Medicare claims data to assess the economic consequences as well as potential impact on patient care and access to neuro-ophthalmologic services by Medicare beneficiaries. When we examined new and return patient visit volumes and distributions for 68,078 family practitioners, 61,168 internal medicine specialists, 11,620 neurologists, and Departments of Ophthalmology, Neurology, and Neurosurgery (PSS), University of Colorado Anschutz Medical Campus, Aurora, Colorado; Departments of Ophthalmology and Neurosciences (LPF), Rutgers- New Jersey Medical School, Newark, New Jersey; and Department of Ophthalmology (VB), Emory University School of Medicine, Atlanta, Georgia. The authors report no conflicts of interest. Address correspondence to Prem S. Subramanian, MD, PhD, UC Health Eye Center, 1675 Aurora Ct, Mail Stop F731, Aurora, CO 80045; E-mail: [e-mail] 4 12,375 ophthalmologists, we found that family practitioners and internists billed 2.9%-3.2% of visits as new patient encounters. Neurologists claimed 17.2%; ophthalmologists, 17.4%. By contrast, 113 neurology-trained North American Neuro-Ophthalmology Society (NANOS) members billed 24.5% of visits as new patient encounters, whereas 240 ophthalmology-trained members claimed 29.1%. Most (.83%) claims submitted by NANOS members were moderate-to-high complexity (CPT 99204, 99205), as were those claimed by all neurologists, all ophthalmologists, and internists (but not family practitioners). Thus, we found that neurologists and ophthalmologists claimed a greater percentage of new patient encounters with Medicare beneficiaries in 2014 than did primary care physicians; neuro-ophthalmologists from both specialties claimed an even greater proportion of such visits. Patients with new onset neuro-ophthalmic disease typically present to a general neurologist or comprehensive ophthalmologist for evaluation of symptoms; this physician will arrange for consultation with a neuro-ophthalmologist. Other subspecialists including neurosurgeons, physiatrists, otolaryngologists, and emergency physicians also commonly request neuroophthalmic consultations. It is uncommon that the neuro-ophthalmologist becomes the primary physician responsible for most or entirety of the patient's medical care and typically remains in a consultative capacity. Business models in both ophthalmology and neurology demonstrate that many new patients are seen without a specific request from another medical provider (5,6). By contrast, most neuro-ophthalmologists require that new patients obtain a consultation request from an appropriate specialty physician to establish that a neuro-ophthalmic concern is present; this is not a specialty that typically has self-referred patients. In the past, consultation codes were reimbursed at a higher rate by CMS to acknowledge the additional time and effort required for patient evaluation. This practice embodied the concept of value-based payment, which is now being proposed as a "new" model of physician reimbursement. For example, in 2009, CPT 99204 was assigned 2.3 physician work-relative value units (wRVU), whereas Subramanian et al: J Neuro-Ophthalmol 2018; 38: 4-6 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Perspective CPT 99244 (representing the same complexity of care) was assigned 3.02 wRVU, for a difference of 0.72 wRVU. Similarly, CPT 99245 was assigned 0.77 wRVU more than CPT 99205. The difference in total RVU is even greater, at 1.21 RVU for the level 4 codes and 1.32 RVU for the level 5 codes. If we make a conservative assumption that 80% of new patient visits to neuroophthalmologists in 2014 would have been coded as consultations, then a total of 12,711 visits would have been billed as CPT 99244 and 6,772 visits as CPT 99245, for an additional 24,319.35 total RVU. This calculation is based on 2009 RVU information because CMS stopped assigning values to consultations after January 1, 2010. Using the 2009 RVU conversion factor of $36.07, an additional payment of $877,198.95 would have been made to neuro-ophthalmologists by CMS. If we were to assume that 100% of all new neuro-ophthalmology patients could be considered consultations, then the total would be $1,096,509.60. Although this figure may seem small, especially on a per-physician basis, it is important to consider that this comes directly out of any potential profit margin that the physician's practice might generate because the cost of delivering care to these patients remains unchanged. Furthermore, our data derive from Medicare patients only, and if other federal and commercial payers follow Medicare's lead in coding and payment practices, the financial impact could at least be doubled, given the payer mix in the typical neuro-ophthalmology practice. In addition, this figure likely underestimates the financial impact of eliminating consultation codes. Because of billing rules, a patient sent in consultation by another provider in the same practice or physician group billing under the same tax ID number cannot be considered a new patient and must be billed as an established patient. The Medicare data do not allow us to identify patient encounters that might fall into this category because we cannot break down encounters to the individual patient level. However, if even 20% of established visits were to have been billed as consultations (a conservative assumption in many academic practices), then an additional $791,925.15 may have been paid to neuro-ophthalmologists for moderate-to-high complexity codes (CPT 99214 or 99215 billed instead as CPT 99244 or 99245). Even if the neuro-ophthalmologist's compensation is not tied directly to billing and collections, the reduced wRVU and overall RVU assigned to new and established patient CPT codes relative to consultation codes causes the neuro-ophthalmologist to appear less productive and possibly subject him/her to financial penalties within an academic department or private practice. However, procedurally oriented subspecialties such as glaucoma and retina are compensated for those procedures at a rate that is independent of the patient's new or return status, whereas cognitive specialSubramanian et al: J Neuro-Ophthalmol 2018; 38: 4-6 ists such as neuro-ophthalmologists must rely on E/M codes to accurately reflect the effort required to deliver patient care. As practicing neuro-ophthalmologists, we clearly have a vested interest in ensuring that our subspecialists are remunerated adequately by CMS. We have no interest in furthering discord between primary care physicians and others (2,3,7,8); rather, our intent is to expose potential flaws in the current system that might adversely impact our patients by limiting their access to cognitive specialty care. The cost savings of neuro-ophthalmic care have been demonstrated in previous research (3,9,10), and our group is engaged in data collection to evaluate the overall quality of neuro-ophthalmic care for specific diseases. Appropriate reimbursement for cognitive specialists may conserve resources by limiting unfocused testing and establishing an earlier diagnosis with timely institution of treatment (11,12). Cognitive subspecialists like neuroophthalmologists cannot simply increase patient volume to make up for lost revenue as their practices are usually operating at capacity because of demand for services. We encourage CMS and private insurers to find a means of recognizing the complex cognitive care that neuroophthalmologists and other similar subspecialists provide to their patients by adopting high-complexity modifiers or similar means to acknowledge the additional time, effort, and complexity in caring for their patients. ACKNOWLEDGMENTS The authors thank Margaret E. 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