You’re a Cataract Surgeon? Here’s How Coding Impacts Your MIPS Cost Score

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News Update (Dec. 7, 2023): CMS seeks public comment on revising cataract cost measure for performance year 2025 . On Dec. 1, CMS announced that it will consider revising the cataract cost measure in its upcoming Medicare rulemaking cycle, with any resulting revisions being implemented in 2025. You can submit feedback on any measure in the 2023 Measures Under Consideration list until Dec. 22. The Academy will attend a public listening session on Dec. 14 to learn more about the measure revisions being considered and will submit its formal recommendations. (Meanwhile, the Academy continues to work with the American Medical Association and other partners to address the problems with cost measures for the 2022 performance year.)

The Merit-Based Incentive Pay­ment System (MIPS) involves four performance categories—cost, quality, improvement activities, and the EHR-based promoting interop­erability. If you are scored on all four of those, the cost performance category would contribute up to 30 points to your MIPS final score.

Which cost measures apply to ophthalmology? During the 2023 performance year, only two of the cost measures are likely to apply to ophthalmologists. Cataract specialists and comprehensive ophthalmologists might be scored on the cost measure for routine cataract surgery, and the melanoma cost measure may apply to some oculofacial subspecialists.

Not everybody will be scored on cost. If you are reporting MIPS as an individual and none of the cost measures are relevant to you, you won’t receive a cost score and the 30 points that are associated with cost would be distributed to one or more other per­formance categories. The same would be true if you were reporting as part of a group and none of the cost measures were relevant to anybody in the group.

You must be a MIPS eligible clini­cian. You won’t be scored on any of the MIPS performance categories unless you are a MIPS eligible clinician. Oph­thalmologists and optometrists who bill for Medicare patients are likely to be MIPS eligible clinicians, though some may be excluded from the program if, for example, they are new to Medicare or fall below the low-volume threshold. To learn more about MIPS eligibility, see “Who Does (and Doesn’t) Take Part in MIPS.” 

An Overview of the Routine Cataract Surgery Measure

As with all cost measures, the Routine Cataract Removal With IOL Implan­tation measure does not involve any additional reporting on your part. Instead, CMS reviews information that is submitted as a matter of course when providers bill for Medicare patients. It uses this data to 1) attribute relevant surgeries to you and 2) track costs that are clinically associated with those procedures.

Which surgeries are attributed to you? In general, an episode of routine cataract surgery will be attributed to the MIPS eligible clinician who performed the procedure that “triggers” the epi­sode. That procedure is known as the “trigger service,” and the day on which it takes place is the “trigger day.”

CPT code 66984 triggers an episode of care. Unless an exclusion applies, an episode of routine cataract surgery will be attributed to you if you bill CPT code 66984 Extracapsular cat­aract removal with insertion of intraoc­ular lens prosthesis (1 stage procedure), manual or mechanical technique (e.g., irrigation and aspiration or phacoemul­sification); without endoscopic cyclo­photocoagulation. (Note: CPT code 66982 for complex cataract surgery would not trigger an episode.)

Exclusions may apply. When deter­mining your score for the cataract cost measure, CMS will exclude surgeries involving significant ocular conditions, such as retinal detachment, that might impact the complication rate or the visual outcome.

Hundreds of ICD-10 codes may prompt an exclusion. In looking for ICD-10 codes that might prompt an exclusion, CMS will review Medicare Part B physician claims, inpatient claims, and outpatient claims with dates of service up to 120 days before the cataract surgery. For the cataract cost measure, there are hundreds of ICD-10 codes that would result in an episode of care being excluded. These include codes for the following diagnoses:

• Type 1 or 2 diabetes mellitus with ophthalmic complications (E10.3-, E11.3-)
• Central corneal ulcer (H16.01-) or opacity (H17.1-)
• Keratoconus (H18.6-)
• Open-angle glaucoma (H40.1-)
• Nonexudative and exudative macu­lar degeneration (H35.3-)
• Chorioretinal inflammation (H30-)

Note: dry eye syndrome (H04.12-) and keratoconjunctivitis (H16.22-) are not excluded diagnoses. For the full list of codes that would prompt an exclusion (including a few CPT codes), download the CMS measure specifications (see “More on Cost”).

A 10-episode case minimum. The cataract measure will only contribute to your cost score if at least 10 episodes of care are attributed to you or, if you are reporting as part of a group, to your group during 2023.

What costs are included? The cataract measure’s specifications include a list of CPT and HCPCS codes whose costs could be assigned to an episode of care (see “Examples of Assignable Costs”). CMS reviews the patient’s Medicare claims over a five-month period to see if any of those codes have been billed. This review period includes a “pre-trigger window,” which is the 60 days prior to the day of surgery (the trigger day) and a 90-day “post-trigger window.”

CMS tries to account for costs that are beyond your control. Your costs for the measure will undergo standard­ization and risk adjustment. This is intended to account for cost variations that are beyond your control, such as geographic variations in practice expenses or patient characteristics that could lead to increased costs, such as patient age or comorbidities.

CMS uses subgroups to compare apples to apples. CMS recognizes that costs can vary depending on whether surgery was done in an ambulatory surgery center (ASC) or a hospital outpatient department (HOPD), and that costs can also vary depending on whether the cataract surgery is unilat­eral or bilateral (which it defines as the second surgery being done within 30 days of the first). Consequently, CMS divides episodes of routine cataract sur­gery into four subgroups and will only compare an episode’s costs against the cost of episodes within the same subgroup. The subgroups for the routine cataract surgery measure are:

• Unilateral surgery in an ASC
• Bilateral surgery in an ASC
• Unilateral surgery in a HOPD
• Bilateral surgery in a HOPD

(Note: the 10-episode case minimum requirement applies to the measure as a whole, not to individual subgroups.)

CMS calculates your score. If your routine cataract surgeries fall within more than one of the subgroups, a weighted average of your subgroup scores will be used to determine your score for the cataract cost measure. Each subgroup score will be based on how your performance compares with that of others within that subgroup.

For a More Accurate Score, Follow Best Coding Practices

When CMS scores you on an episode-based cost measure, such as the routine cataract surgery measure, the agency uses the Medicare billing history to account for factors that might unfairly skew your score. However, the agency can take those factors into account and calculate costs fairly only if services are coded correctly. You should therefore review your use of CPT codes, Category III codes, HCPCS codes, ICD-10 codes, modifiers, and place of service codes—and, if appropriate, educate other providers on correct coding.

If a cataract evaluation determines that surgery is needed, report all relevant ICD-10 codes. Reporting the diagnoses that pertain to a patient encounter is a basic ICD-10 coding principle. By adhering to that, you can ensure that episodes of care are excluded appropriately. For example, if a patient has primary open-angle glaucoma and diabetic retinopathy and these problems were assessed at the cataract evaluation, make sure you report the ICD-10 codes for all of those diagnoses, not just the code for the cataract diagnosis.

Use laterality modifiers. Another coding rule is to always append the appropriate laterality modifier (–RT, –LT, or –50) to surgical CPT codes. For example, when billing for routine cataract surgery in the right eye, report 66984–RT. If you aren’t using the laterality modifiers, and you perform cataract surgery on the left eye within 90 days of that first surgery, the cost for both eyes will count toward both episodes, essentially doubling the calculation.

And beyond MIPS, the absence of the laterality modifier can cause claim denials or prompt a payer review to confirm that you aren’t billing twice for cataract surgery in the same eye.

Use the correct place of service (POS) code. When calculating costs for a cataract surgery, CMS will include facility costs. Those can vary greatly between the ASC and the HOPD, so make sure the surgery is allocated to the appropriate subgroup by reporting the correct POS code:

• 19 for off campus HOPD
• 22 for on campus HOPD
• 24 for ASC

Billing for evaluations can impact an episode’s costs. ASCs and hospitals often require a history and physical (H+P) before cataract surgery, but billing for that will increase the costs associated with the procedure. If a limited examination is necessary, the surgeon may provide the H+P as a part of a nonbillable preoperative visit or during the cataract evaluation.

Watch out for how other specialists bill for consults. Suppose the patient’s primary care provider orders a consul­tation for a nonophthalmic condition, such as chronic obstructive pulmonary disease (COPD). If the consulting physician bills for the visit using the cataract ICD-10 code in addition to the COPD ICD-10 code, the costs of that consultation and subsequent workups and tests will count toward your epi­sode of care if they fall within the five months of Medicare billings reviewed by CMS. Without the cataract ICD-10 code on the claim, the costs won’t be included.

In summary. Although not all costs associated with routine cataract surgery can be controlled, you can impact your score by adhering to fundamental coding principles and reviewing the cataract measure specifications to see which services might be assigned to your episode of care.