Coding & Reimbursement

Protect your MIPS Cost score

A great deal has been written about CMS’ Quality Payment Program and MIPS, and we are not going to rehash all of that here. However, in 2019, we are faced with a brand new episode-based cost measure for ophthalmology — Routine Cataract Removal with IOL Implantation — that will impact many practices’ MIPS Cost score. Read on for the details.

Q. What is an episode-based cost measure?

A. Episode-based cost measures represent the cost to Medicare for the items and services provided to a patient during an episode of care. In all supplemental documentation, “cost” generally means the standardized Medicare-allowed amount, which includes both Medicare and trust fund payments, as well as any applicable beneficiary deductible and coinsurance amounts.

Q. How does this apply to cataract?

A. The Routine Cataract Removal with IOL Implantation episode-based cost measure evaluates a clinician’s risk-adjusted cost to Medicare for beneficiaries who undergo routine cataract removal with IOL during the performance period (CY 2019). The sole episode-based cost measure applied to ophthalmologists is the cataract surgery episode measure. This is because it is the only one related to any ocular procedures or conditions.

The cost measure score is the clinician’s risk-adjusted cost for the episode group averaged across all episodes attributed to the clinician. This procedural measure includes costs of services that are clinically related to the attributed clinician’s role during each episode. An episode starts 60 days prior to the clinical event that opens, or “triggers,” the episode through 90 days after the trigger.

The episode-based measures seek to quantify the cost of care related to a specific procedure or condition, and include the total costs of preoperative testing, the surgery itself, facility costs, anesthesia costs and postoperative care not included in the global surgical bundle.

Q. What costs are included?

A. For procedural episodes, CMS will attribute episodes to a MIPS-eligible clinician who renders a trigger service (in this case, 66984). Pertinent costs fall within a time window of 60 days prior to the trigger service and 90 days afterward. Only covered items and services are counted. The cost of noncovered items and services, on the other hand, are ignored.

For example, an eye exam to determine the need for cataract surgery and the associated biometry to select an IOL power are counted. Anesthesia is counted. The ASC or HOPD facility fee is counted. Any injected medications during surgery, such as pass-through drugs that receive separate payment, are counted. Importantly, the treatment of complications paid for by Part B Medicare within the 90-day postop period, whether by the surgeon or other eye-care physician, is counted.

Example: Clinician A performs cataract surgery with IOL (66984) for Patient K on Jan. 2, 2019. This service triggers a Routine Cataract Removal with IOL Implantation episode, which is attributed to Clinician A. Clinician B performs a lens repositioning procedure, which is considered a clinically related service, during the episode window on Jan. 11, 2019. Because lens repositioning is considered to be clinically related to the triggering procedure, the cost of the repositioning procedure will be assigned to Clinician A’s episode.

Q. What costs are excluded?

A. A number of things, and not all cataract cases count. First, and most important, this is a Medicare Part B program only; any other patients are excluded from the calculation. Second, this is only regular cataract surgery (66984); complex cataract surgery (66982) is excluded. Patients with significant co-morbidities, as described in CMS quality measure #191, do not count; CMS has said it will use a 120-day look back period to identify these co-morbidities (eg, iridocyclitis, corneal ulcer, glaucoma, posterior segment disease).

In addition, non-covered items and services are excluded. Patient-pay refractive services, like astigmatism correction and toric or presbyopia-correcting IOLs, are not included.

Q. Surgery performed at a HOPD has considerably higher costs than an ASC. Do HOPD-based surgeons always take a hit?

A. No. CMS has considered this factor and uses different risk-adjusted cost calculations for HOPD and ASC. CMS recognizes that HOPD-allowed amounts are greater. However, since the episode-based cost is a new element of MIPS, we cannot be sure how this will be applied.

Q. What can we do to minimize our costs?

A. Consider the following options to minimize your costs:

  • Review pertinent co-morbid diagnoses on eye exams; be sure these are reported on claims
  • Expand ICD-10 coding for cataract surgery
  • Attend to differences between routine and complex; be sure your operative reports are clear and complete
  • Minimize complications; eg, YAG capsulotomy within 90 days, CME after cataract surgery
  • Reduce unusual costs (eg, pass-through drugs)
  • Choose ASC over HOPD when medically appropriate
  • Explore alternatives:
    • Bilateral cataract surgery
    • In-office cataract surgery OM


  1. CMS Measure Specification Sheet, Quality Measure #191. [Author’s note: The CMS web site is set up such that no direct link to the Measure file is available.]