Article

Coding & Reimbursement

Coding trends, 2015-2016

Practice patterns do not remain constant, so comparing year-over-year is always worthwhile. When we compare Medicare data for 2016, the most recent year currently available, with the prior year (2015), we see some interesting things.

Q. Were there large changes for diagnostic tests?

A. There were. Table 1 shows some of the most dramatic increases for ophthalmology. Table 2 shows some of the most significant decreases.

TABLE 1. OPHTHALMIC TESTING: INCREASES
DESCRIPTION CODE 2015 2016 DIFFERENCE CHANGE %
Immunoassay test 83516 36,324 79,205 42,881 118%
Ultrasonic biomicroscopy 76513 15,797 28,309 12,512 79%
Corneal pachymetry 76514 353,036 599,294 246,258 70%
B-Scan 76512 167,439 279,198 111,759 67%
A-Scan (for tumors, etc.) 76510 14,979 20,924 5,945 40%
A-Scan with IOL calculation 76519 321,763 444,357 122,594 38%
Electroretinography 92275 58,376 76,131 17,755 30%
OCT anterior segment 92132 29,054 35,284 6,230 21%
Corneal topography 92025 143,092 163,938 20,846 15%
OCT retina 92134 5,294,803 5,766,010 471,207 9%
Optical coherence biometry with IOL calculation 92136 1,448,173 1,549,931 101,758 7%
TABLE 2. OPHTHALMIC TESTING: DECREASES
DESCRIPTION CODE 2015 2016 DIFFERENCE CHANGE %
Allergy testing 92165 12,432 7,618 -4,814 -39%
Nursing home visit 99305 11,028 7,133 -3,895 -35%
Nursing home visit 99308 13,419 9,000 -4,419 -33%
Allergy testing 95004 638,135 487,020 -151,115 -24%
Ext. ophthalmoscopy 92226 2,567,476 2,116,828 -450,548 -18%
Fluorescein angiography 92235 1,251,945 1,046,851 -205,094 -16%
Visual field, intermediate 92082 82,777 74,511 -8,266 -10%
OCT anterior segment 92132 29,054 35,284 6,230 21%
Corneal topography 92025 143,092 163,938 20,846 15%
OCT retina 92134 5,294,803 5,766,010 471,207 9%
Optical coherence biometry with IOL calculation 92136 1,448,173 1,549,931 101,758 7%

In many cases, the actual frequency is low, but the percentage changes are large, such as immunoassay, a lab test for dry eye. For other codes, the percentage changes are modest, such as for OCT of the retina, but the sheer volume makes it important.

Q. How about surgical procedures?

A. For ophthalmic surgery, Table 3 identifies the big changes in utilization, both up and down.

TABLE 3. OPHTHALMIC SURGERY
DESCRIPTION CODE 2015 2016 DIFFERENCE % CHANGE
iStent (Glaukos) 0191T 28,758 42,266 13,498 47%
Temporary amniotic membrane 65778 11,137 16,037 4,900 44%
Intravitreal injection 67028 2,959,021 3,215,435 256,414 9%
Paracentesis 65800 37,547 27,607 -9,940 -26%
Subconjunctival injection 68200 18,363 9,857 -8,506 -46%

It is no surprise that the number of minimally invasive glaucoma surgery (MIGS) procedures continues to increase. The only code with any history is 0191T (iStent). Although other devices are being used now, they are new and no data yet exist.

The frequency of intravitreal injections continues to rise. It is currently the most common ophthalmic procedure, surpassing even cataract surgery. As with the related OCT of the retina, shown in Table 1, the percentage change is not great, but the volume is important.

We also looked at the use of supplies, especially injectable medications. Table 4 shows the relative volume of these supplies year-over-year. Note particularly the two largest numbers — aflibercept (Eylea, Regeneron) and ranibizumab (Lucentis, Genentech). You can readily see the growth in use of Eylea, while Lucentis’ declined, although not as much — use of these drugs continues to increase overall. Interestingly, although the data are less obvious, we can also see a decline in utilization of Avastin, which is reported with various miscellaneous J-codes.

TABLE 4. OPHTHALMIC SUPPLIES
DESCRIPTION CODE 2015 2016 DIFFERENCE % CHANGE
AbobotulinumtoxinA (Dysport)* J0586 12,277 17,389 5,112 42%
IncobotulinumtoxinA (Xeomin)* J0588 170,164 212,067 41,903 25%
Aflibercept (Eylea)* J0178 1,765,543 2,152,831 387,288 22%
Dexamethasone (Ozurdex)* J7312 156,174 190,205 34,031 22%
Triamcinolone (Kenalog)* J3301 80,178 91,887 11,709 15%
Ranibizumab (Lucentis)* J2778 2,864,867 2,663,875 -200,992 -7%
Misc. biologics (incl. Avastin)* J3590 365,557 222,548 -143,009 -39%
Misc. drugs (incl. Avastin)* J3490 71,618 35,751 -35,867 -50%

Q. Were there significant changes in exam coding?

A. Yes, although not as dramatic as those for tests and procedures. Table 5 shows these numbers. The overall frequency of exams paid by Medicare decreased a bit. The only segment to increase was established patient eye codes; evaluation and management (E/M) code frequency decreased across the board, as did new patient eye codes.

TABLE 5. OPHTHALMIC EXAMS
DESCRIPTION CODE 2015 2016 DIFFERENCE % CHANGE
New patient E/M 9920x 998,796 884,854 -113,942 -11.4%
Established patient E/M 9921x 4,317,239 4,032,796 -284,443 -6.6%
New patient Eye 9200x 1,451,157 1,445,973 -5,184 -0.4%
Established patient Eye 9201x 13,983,608 14,164,969 181,361 1.3%
Totals 20,750,800 20,528,592 -222,208 -1.1%

If your practice patterns vary considerably from the average, in all categories of codes, you face increased risk of unwanted attention. Keep in mind that careful documentation of both the service and its medical necessity is your best defense. OM

*Dysport, Ipsen Biopharmaceuticals, Inc; Xeomin, Merz North America, Inc.; Eylea, Regeneron Pharmaceuticals, Inc.; Ozurdex, Allergan, Inc.; Kenalog, Bristol-Myers Squibb Co.; Lucentis, Genentech USA, Inc.; Avastin, Genentech USA, Inc.; iStent, Glaukos Corp.