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Fi Financial i l Disclosure D l Di Kevin Corcoran is Presid dent of Corcoran Consulting Group and Fo ounder of Corcoran Compliance Connection and acknowledges a financial interest in the subject matter of this presentation. presentation

Ophthalmology Practice Trends

Kevin J J. Corcoran Corcoran, CO OE CPC, OE, CPC CPMA, CPMA FNAO President, Corcoran Consulting Group Founder Corcoran Co Founder, ompliance Connection

Medicarre Data • Part B Extract Summary Syystem (BESS) • Excludes: • Non-Medicare • Medicare Advantage

Medicare Enrollment E 55.0 50.0 45 0 45.0 Beneficaries (M)

40.0 35.0 30.0

Medicare Traditional Advantage

25.0 20 0 20.0 15.0 10.0 5.0 0.0 1998

2000

2002

2004

2006 Year

2008

2010

2012

2014

Eye Ex xams Medicare Eye E Exams 25,000,000 22,500,000

Ey ye Exams

20,000,000 17 500 000 17,500,000 15,000,000 MD Exams OD Exams

12,500,000 10,000,000 7,500,000 5,000,000 2,500,000

2000

2002

2004

2006 2008 Yea ar

2010

2012

2014

Diagnostic c Testing Common Diag gnostic Tests 22,500,000 20,000,000 17,500,000

Tests

15 000 000 15,000,000 12,500,000 MD Tests OD Tests

10,000,000 7,500,000 5,000,000 2,500,000 2000

2002

2004

2006 2008 Y Year

2010

2012

2014

Cataract Surgery 2,000,000 1,900,000 1,800,000

P Procedur res

1,700,000 1,600,000 1,500,000 1,400,000 1,300,000 1,200,000 1 100 000 1,100,000 1,000,000 1996

1998

2000

2002

2 2004

2006

Year

2008

2010

2012

2014

Cataract Surgery Top 2 Catara act Surgeries 2,000,000 1,800,000

Pro ocedures s

1,600,000 1,400,000 , , 1,200,000 1,000,000

66984 66982

800 000 800,000 600,000 400,000 200,000 0 1995

2000

2 2005

Ye ears

2010

2015

Cataract Surgery 3,500,000 3,000,000 , , 2,500,000 2,000,000 1,500,000

Non-Medicare MA Reg. Medicare

1,000,000 500,000 0

Glaucoma a Surgery 400,000 350,000 300,000

Proccedures

250 000 250,000 200,000 150,000 100,000 50,000 0 1990

1995

2000 0

2005

Year

2010

2015

Glaucoma a Surgery Top 3 Glauco oma Surgeries 200,000 180,000

Pro ocedures s

160,000 140,000 120,000 100,000

65855 66761 66170

80 000 80,000 60,000 40,000 20 000 20,000 0 1990

1995

2000

2005

Ye ear

2010

2015

Retina Surgery S 3,000,000

P Procedu res

2,500,000 2,000,000 1,500,000 1 000 000 1,000,000 500,000 0 1996

1998

2000

2002

2004

2006

Year

2008

2010

2012

2014

Retina Surgery S Top 3 Retina a Surgeries 2,500,000

Pro ocedures s

2,000,000 1,500,000 67028 6 67210 0 67228

1 000 000 1,000,000 500,000 0 1995

2000

005 20

Ye ear

2010

2015

Oculoplastic Surgery Eyelid Surgery S 250 000 250,000

Pro oceduress

200,000 150,000 100,000 00,000 50,000 0 1998

2000

2002

2004

2006

Year

2008

2010

2012

2014

Procedures

Oculoplastic Surgery Top 3 Oculoplastic Surgeries 100,000 90,000 80,000 70,000 60,000 50,000

15823 67904 67917

40,000 30,000 20,000 10 000 10,000 1998

2000

2002

2004

20 006

Ye ear

2008

2010

2012

2014

Office Visits V Medicare Utilization Patterns Ophthalmology (18)

CPT 9205 9204

New Patients

Level 5 E/M Level 4 E/M

λ 3% 29%

Level 3 E/M 9203 61%* 2004 Comprehensive Eye 9202 Level 2 E/M 6%* 2002 Intermediate Eye 9201 Level 1 E/M <1%

CPT Established Patients λ 9 99215 Level 5 E/M 1% 9 99214 Level 4 E/M 52% Comprehensive Eye 9 92014 Level 3 E/M 9 99213 43% 9 92012 Intermediate Eye 9 99212 Level 2 E/M 4% 9 99211

ombined utilization of E/M and eye codes s

ource: CMS data 2012, 18 - Ophthalmology

Level 1 E/M

<1%

Office Visits V Medicare Utilization Patterns Ophthalmology (18)

CPT

New Patients

λ

CPT

9203 2004

Level 3 E/M Comp Eye Exam

8% 53%

99214 92014

Comp Eye Exam

7% 45%

9202 2002

Levell 2 E/M L Intermediate Eye

1% 5%

99213 92012

Levell 3 E/M L Intermediate Eye

13% 30%

ource: CMS data 2012, 18 - Ophthalmolo ogy

Established Patients Level 4 E/M

λ

Office e Visits Medicare Utilization P Patterns Optometry (41)

CPT 9205 9204

New Patients

Level 5 E/M Level 4 E/M

λ <1% 12%

9203 2004 9202 2002

Level 3 E/M

78%*

9201

Comprehensive Eye

Level 2 E/M 10%* Intermediate Eye Level 1 E/M <1%

CPT Established Patients λ 99215 Level 5 E/M <1 99214 Level 4 E/M 56% C h i E Eye 92014 Comprehensive 99213 Level 3 E/M 36% 92012 Intermediate Eye y 99212 Level 2 E/M 7% 99211

ombined utilization of E/M and eye codes s

ource: CMS data 2012, 41 - Optometry

Level 1 E/M

<1

Office Visits V Medicare Utilization Patterns Optometry (41)

CPT

New Patients

λ

CPT

9203 2004

Level 3 E/M Comp Eye Exam

10% 68%

99214 92014

Comp Eye Exam

11% 45%

9202 2002

Levell 2 E/M L Intermediate Eye

3% 7%

99213 92012

Levell 3 E/M L Intermediate Eye

19% 17%

ource: CMS data 2012, 41 - Optometry

Established Patients Level 4 E/M

λ

Common Oph hthalmic Tests Medicare Utilization Patte erns (18 - Ophthalmology)

CPT 2134 222 222x 208x -

Procedure λ Scanning Laser (retina) 19% % E O Ext Ophthalmoscopy hh l 18% % Perimetry 10% % Biometry (A or OCB) 8% % % 2133 Scanning Laser (glauc) 8%

CPT 92250 92235 92020 76514 92285

Frequency is per 100 office visits (%) on Medicare beneficiaries

Source: CMS data (2012), 18 – Ophthalmology

Procedure Fundus Photo Fl Fluorescein i Gonioscopy Pachymetry External Photos

λ 8% 7% 3% 2% 1%

Common Oph hthalmic Tests Medicare Utilization Pa atterns (41 - Optometry)

CPT Procedure 92250 Fundus Photo

λ 13% %

CPT Procedure 92133 Scanning Laser

λ 6%

9208x Perimetry

10% %

92134 Scanning Laser

4%

9222x Ext 9222 E Ophthalmoscopy O hh l 92020 Gonioscopy

(glaucoma) (retina)

6% 2%

92285 External E l Ph Photo 76514 Pachymetry

Frequency is per 100 office visits (%) on Medicare beneficiaries

Source: CMS data (2012), 41 – Optometry

1% 1%

Common Ophth halmic Surgery Medicare Utilization Patterns (18 - Ophthalmology)

CPT Procedure 67028 Intravitreal injection 66984 Cataract & IOL

λ 11%

CPT Procedure 6 68761 Punctum plugs

λ 1%

8%

1%

66821 YAG 66761 Glaucoma laser 65855

3% 1%

67228 Retina laser 6 6 67210 6 67820 Epilation 15823 Blepharoplasty

Frequency is per 100 office visits (%) on Medicare beneficiaries

Source: CMS data (2012), 18 – Ophthalmology

1% 1%

Medicare Utilization U 67028 Utiilization 2,500,000 Proc cedures

2 000 000 2,000,000 1,500,000 1 000 000 1,000,000 500,000 0

1996

1998

2000

2002

2004

Source: CMS data (1998 – 2012), 18 – Ophthalm mology

2006

2008

2010

2012

Common Minor Eye Surgeries Medicare Utilization Patterns Ophthalmology (18)

CPT 67028 68761 67820 65855

Procedurre Intravitreal injection Punctum occlusion, occlusion plug Epilation, forceps Laser trabeculoplasty

Frequency is per 100 office visits (%) on Medicare beneficiaries

Source: CMS data (2012), 18 – Ophthalmology

λ 11.0% 1 3% 1.3% 1.0% 1.0%

Changes to Pra actice Patterns Ophthalmo ology (18)

ncreases Tear osmolarity (83861) +496% Serial tonometry (92100) +29% OCT retina OCT, ti (92134) +16% ICG (92240) +16% IV injection (67028) +15% A-scan (76510) +14% Topography p g p y ((92025)) +12% OCT, anterior (92132) +12% Cell count (92286) +11%

Decreases • • • • •

PDT (67221) -30% Laser choroid (67220) -16% A A-scan w/IOL /IOL (76519) -11% 11% Cautery punctum (68760) -11% E/M level 2 est est. (99212) -9%

Source: CMS data 2011 vs. 2012, 18 – Oph hthalmology

Top 10 Ophthallmic Procedures Medicare Utilization Pattterns Ophthalmology (18)

Rank

CPT

Procedure

Rank

Intravitreal

CPT

Procedure

1

67028 Injection

6

66982 Complex Cataract

2

66984 Cataract w/IOL

7

65855 Lx Trabeculoplasty

3

p y 66821 YAG capsulotomy

8

67210 Focal Laser

4

68761 Punctum plug

9

15823 Blepharoplasty

5

67820 Epilation

10

67228 PRP

ource: CMS data 2012, 18 - Ophthalmolo ogy

Changes to Pra actice Patterns Optome etry (41)

ncreases Tear osmolarity (83861) +540% VEP (95930) +371% OCT anterior OCT, t i (92132) +40% OCT, retina (92134) +18% Cell count (92286) +17% Topography (92025) +15% Orthoptic p training g ((92065)) +10%

Decreases • FB (65205) • Nursing home (99310)

Source: CMS data 2011 vs. 2012, 41 - Opto ometry

-16% -15%

Top 10 Optome etric Procedures Medicare Utilization P Patterns Optometry (41)

Rank

CPT

Procedure

Rank

CPT

Procedure

1

92250 Fundus Photo

6

92226 EO, subsequent

2

P i t 92083 Perimetry

7

G i 92020 Gonioscopy

3

92133 SCODI – nerve

8

68761 Punctum plug

4

92134 SCODI – macula

9

92285 External photo

5

EO iinitial iti l 92225 EO,

ource: CMS data 2012, 41 – Optometry

10

E il ti 67820 Epilation

Summ mary • Growing Medicare populatio on, especially in MA plans • Growing gp presence of optom p metryy within Medicare • Distribution of exams shiftin ng • Growth in testing, testing especiallyy imaging • Increasing surgical volume:: cataract, AMD • Future F me • Higher procedure volum • Payment reform

Ophthalmolo ogist Trends Ophthalmolog gists Trends 26000

Ophthalmologis sts

25000 24000 23000 Expected Oph

22000

Required Oph

21000 20000 19000 18000 1995

2000

2005

2010 Year

2015

2020

Sources: DHHS Physician Supply and Dema and Projections to 2020

2025

Optometris sts Trends Optometris sts Trends 50000 47500 Optometris sts

45000 2 00 42500 Expected Required

40000 37500 35000 32500 30000 1995

2000

2005

2010

2015 Year

2020

2025

2030

2035

Sources: White, AJ., Workforce Projections for Optometry, Abt Study, 2000

Changes To Payme ent Methodology

• Bundling of services are • Payment for episodes of ca • Capitation p • Full capitation • Contact capitation a ue based pu purchasing c as g • Value • Lower cost and equal or o better outcomes = value

• • • •

Key Factors forr Next 10 Years Continued US economic gro owth (2.5%) Slower growth in health carre spending (1% per year) FFS payments down 13-17% g demand ((27% mo ore encounters)) Growing • ≥65 y/o • 18-64 y/o • ≤18

75% increase e in volume 24% 4%

• More insured lives also fuells demand • Medicare/Medicaid expand 33%

• • • • •

Key Factors (continued) MD supply stagnates; OD supply s expands PA and NP add very little to o manpower More part time doctors (22% % of total) Modest p productivity y increasse (10%) ( ) Provider compensation incrreases slightly (8%) • Increasing c eas g e efficiency c e cy a an nd d pat patient e t ttriage age p produce oduce greater provider compe ensation

What’s Ne ew in 2014 • • • • • • • •

Medicare Advantage q Sequestration ICD-10 HIT penalties, MU RVU changes, CF Audits overpayments Audits, HIPAA Facility payment updates

Medicare Adv vantage Plans • United Healthcare includin ng ophthalmologists in their Premium Designation Prog gram • Places physicians in a tier on qua quality ya and d cos cost efficiency e c e cy • Judged o • Some plans incentivize e patients to use tier-one p o de s providers

Source: https://www.unitedhealthcareonline.com//b2c/CmaAction.do?chan nelId=6956eb70a73a7310VgnVCM1000 000294ab10a____

Seques stration • Sequestration ordered as of o March 1, 2013 • Reduces Medicare FFS byy 2% • Affects providers, facility, and DME • Dates of service on or after 4/1/13 • Reduction taken after coinsurance c and deductible •U Unassigned ass g ed cclaims a sa als sso subject to reduction educt o • Medicare EHR incentive pa ayments reduced by 2% • PQRS and E E-Rx Rx 2013 ince entive payments reduced by 2% Source: ASCRS Washington Watch Weekly 3/8 8/13; https://www.cms.gov/Outreach-and-Education/O Outreach/NPC/Downloads/FinalAnnouncement-7-25-2013-NPC-Call.pdf

ICD-10-CM Im mplementation • Health and Human Service es (HHS) Secretary Kathleen G. Sebelius anno ounced a delay for ICD-10 implementation to Octoberr 1, 2014 • Expect more updates to th he ICD-10-CM Manual

ICD-10-C CM Testing • CMS announced a testing g week to check ability to transmit claims with ICD-1 10-CM codes • March 3-7, 2014 d dua Medicare ed ca e Admin d nistrative s a e Co Contractors ac o s ((MAC) C) • Individual to publish information rega arding registering to test

Source: MLN Matters Number MM846 65

CMS Bonus s Programs • Physician’s Quality Reportting System (PQRS) • E-Prescribing • Health Information Techno ology (HIT) Incentives

PQRS • PPACA makes PQRS man ndatory by 2015 • Bonus payment decreased d in 2012 to 0.5% for 2012 – 2014 b reduced by 2% due to • 2013 bonus payment will be sequestration t ti • Punitive (-1.5%) if not partticipating in 2015; -2% in 2016 and beyond

Source: Patient Protection & Afford dable Care Act (PPACA)

IRIS™ Registry R • IRIS™ registry (Intelligent Research R In Sight), the nation’s first comprehensive e eye disease clinical registry • Enables ophthalmologists to use clinical data to improve care delivery and patient outcomes o • Helps ophthalmology pracctices meet the requirements of the federal Physician Quallity Reporting System (PQRS), Meaningful use, and the Value V Based Modifier, thus streamlining the way to quality-based payment • Uses scientificallyy valid an nd HIPAA-compliant p methods to collect data from patient re ecords – directly from electronic health record (EHR) systems • Launches March 25, 25 2014 Source: AAO

http://www.aao.org g/iris-registry/index.cfm

Electronic Pres scribing (E-Rx) • PPACA made E-Rx manda atory by 2012 • Bonus p payment y in 2013 = 0.5%; %; subject j to 2% % reduction due to sequestra ation • Punitive u e ((-2%) %) in 2014 0 a and d beyo beyond d if not o pa participating c pa g • No bonus in 2014 • Cannot qualify for E E-Rx Rx bo onus if seeking HIT bonus

Source: Patient Protection & Afford dable Care Act (PPACA)

Health Information Technology (HIT)

• Component of the American n Recovery and Reinvestmen Act • Penalties begin in 2015 if not participating • Requires “meaningful use” of healthcare IT • Certified EHR technolog gy • Information exchange • Reporting of measures using EHR

When should I sta art demonstrating “ “meaning i ful f l use”? ”? • 2014 • Must demonstrate meaningful use for 3 months 1 20 014 and complete by • Must start by July 1, October 1, 2014 to avoid penalties in 2015 ps to $24 $24,000 000 • Potential incentive drop

CMS Extends Stag ge 2 MU Timeline • Extend timeline for stage 2 MU through 2016 • Delay y stage g 3 MU to 2017 • Stage 2 MU implementatio on on schedule for 2014 • Providers who successfully attested to stage 1 MU in 2012 and 2013, will attest to stage 2 in 2014 • Attestation in 2014 is for 90 days

ASCRS / ASOA Alert, 12/10/13

Financial Penalties Year

Penalty

2015

1% (Paid at 99%)

2016

2 (Paid at 98%) 2%

2017

3 (Paid at 97%) 3%

Beyond

Up to 5%

* Sec Secretary eta y of o HHS S authorize aut o e ed to put in p place ace financial a ca penalties for non-meaningfull users up to 5% beginning in 2019

EHR Bonus Audits

• Figliozzi and Company – CP PA firm in Garden City, NY • Audit notification letter sent via email • Letter requests 4 types of documentation 1. 2. 3. 4.

EHR is certified ER admissions Claims satisfied MU objectives and measures Claims satisfied volunta ary MU objectives and measures

• Documentation D i to b be sent within wi hi two weeks k off request Source: http://www.cms.gov/Regulations-a andGuidance/Legislation/EHRIncentiveProgram ms/Attestation.html#10

• • • • • • • • • •

2014 Relative Value Unit Changes Repair entropion, suture (67921) Repair ectropion, suture (67914) BCL fitting (92071) Fitting of CL, keratoconus (92 2072) Repair ectropion, tarsal wedge (67916) E/M new patient level 4 (9920 04) Intermediate Eye exam (92012) Visual field (92083) Fundus photos (92250) Placement of amniotic tissue (65778) Percentage change from 2013

15% 13% 8% 4% 3% -5% -5% -7% -8% -10%

Medicare Conv version Factor 42.55 37.5 32.5 27.5 22 5 22.5

1997

1999

2001

2003

2005

YEAR

2007

2009

2011

2013

2015

Recovery Audit Co ontractors Update • Program expanded to includ de Part C and D RACs • Medicaid RAC programs in place • Individual states to conttract with a RAC • States determine targetts for scrutiny

Source: CMS website; http://www.medicaiid-rac.com/legislation/

http://www.cms.gov/Medicare-Medicaid-C p g Coordination/FraudPrevention/MedicaidIntegrityProgram/Dow wnloads/Medicaid_RAC_ FAQ.pdf

High Profille Targets • • • •

New patient office visits n EMR Level 4, 5 E/M codes within Blepharoplasty p cedure ((modifier -25)) Exam on dayy of minor proc

ASC Paym ment 2014 • Consumer Price Index (CP PI) and Multifactor Productivity Adjustment up pdates conversion factor by 1.2%

Source: CMS-1601-FC

ASC Paym ment Rates CPT

Procedure

66984 ECCE w IOL 66821 YAG Capsulotomy 66180 Aqueous Shunt

15823 Blepharoplasty

2 2012

2013

2014

$964.64 $964 64 $218.59 $1 1,681.49

$971.02 $971 02 $230.51 $1,671.00

$975.58 $975 58 $236.57 $1,677.90

$861.74

$847.34

$757.47

Source: 2014 rates – CMS-1601-FC Addend dum AA

CPT 66984 66821 66170 66180

HOPD Medicare Payment Rates Procedure ECCE w IOL YAG Capsulotomy Trabeculectomyy Aqueous Shunt

20 012 $1,,672.05 378.93 1630.33 2 2911.11

Source: 2014 rates – CMS-1601-FC Addendu um B

2013 $1,730.47 410.79 1676.62 2977.93

2014 $1,766.0 428.2 1748.9 3037.3

HIPAA Viiolations • Two month investigation by b Pittsburgh TribuneReview revealed Veteranss Administration committed numerous privacy violation ns from 2010 – May 2013 • 14,215 privacy violations in nvolving 101,018 veterans and 551 VA staffers m websites • Posting of PHI on social media • Prescription theft • Failing to encrypt information • Failing to confirm fax numb bers Source: http://www.fierceemr.com/storry/va-overrun-privacyviolations/2013-10-15

HIPAA Priv vacy Rule Reporting of breach: 1 Individual notice to the pa 1. atient(s) within 60 days following the discovery 2 If > 500 patients 2. patients, notify m media outlets in the area within 60 days of discove ery 3 Notify secretary of DHHS 3. S with breach reporting form on HHS website. If > 500 patients report “without reasonable dela ay”, y , no later than 60 days. y If < 500 report on an ann nual basis. Source: http://www.hhs.gov/ocr/privacy/hipaa/a administrative/breachnotifica tionrule/brinstruction.html

Executive Summary • Expanding HIT g regulatory g y comp p plexity y • Increasing • Greater oversight • Small payment changes

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