A friend of mine in London writes:

“Hi Mark,
Could you clarify something I was asked by a colleague yesterday, please? We were discussing anterior vitrectomy, and she asked if there was an additional surgical fee payable in the US for a pars plana approach above a limbal approach? I had no idea and wasn't keen to speculate! Thinking about it, I would assume that there is, and if so, then what order of magnitude is it? Thanks for your help.”

Here is my answer.  First, a disclaimer: The reimbursement values for specific procedures vary with the Medicare “carrier,” that is, the company that administers the Medicare program in a specific region of the country. So, although there are 9 (I think) carriers in the United States, I am providing rounded-up dollar numbers based on our regional carrier in Oregon. Also, in this analysis, I am discussing surgeon fees only, not facility fees. (Reimbursement for the surgery center is separate, and does not really vary much in these different scenarios).

The first principle of Medicare reimbursement is providing the CPT code. The second principle is “bundling” of certain codes together (only one code of several will be reimbursed if charged at the same visit). The third principle is that if two “unbundled” codes are charged on the same day, then the one listed first is reimbursed at 100%, the next is reimbursed at 50%. If a third code is listed, it gets 25%, and so on. (We always list the higher reimbursement first).  

When a vitrectomy—any type—is unplanned (ie, occurs as a result of a complication during cataract surgery and was not listed as a planned procedure preoperatively), there is no reimbursement for it—zero. It is “bundled” with the cataract code (66984 for routine, 66982 for complex—meaning I used a capsular tension ring, iris hooks, or a pupil ring).

Now, suppose I plan a vitrectomy (eg, I am going to place a secondary IOL for aphakia with vitreous prolapse). There are two ways I can do the vitrectomy.

Scenario one—anterior vit: total $805

66985 Secondary IOL $660 @ 100% = $660
67005 Anterior Vit $410 @ 50% = $205

Scenario two—PPV: total $1170

67036 Pars plana Vit $840 @ 100% = $840
66985 Secondary IOL $660 @ 50% = $330

Suppose I want to decompress the vitreous in nanophthalmos prior to phaco in an eye with IFIS and then use iris hooks: total $1350

66982 Complex Cat $930 @ 100% = $930
67036 Pars plana Vit $840 @ 50% = $420

Same scenario without iris hooks (Shugar-caine only): total $1175

67036 Pars plana vit $840 @ 100% = $840
66984 Routine Cat $670 @ 50% = $335

It’s interesting—there is a higher value placed on PPV, but this has nothing to do with whether it is a “better” (ie, safer and more effective procedure) for removing vitreous in preparation for placing a secondary IOL. Similarly, I am paid more for using iris hooks, but in fact many eyes with IFIS do perfectly well without them, and the extra time involved in putting them in may eat up the extra reimbursement anyway. The reimbursements are determined by the RVUs (relative value units) assigned to each procedure—and these are determined by the work, practice expense, and professional liability related to the code, as well as the geography in which one practices.

It would be nice if the personal financial incentives were actually aligned with better outcomes for patients. Doing that would require greater specificity in the coding, because an pars plana vitrectomy may be the best or only approach in one situation (vitreous decompression prior to phaco) but not as good in another (secondary IOL). In many cases, we don’t know which way is better because there is no definitive prospective randomized clinical trial data.

Where do RVUs come from? The RVS Update Committee (RUC). Take a look at this page for more information: “The Resource Based Relative Value Scale.” The RVU is multiplied by a conversion factor each year to determine the reimbursement level for specific CPT codes. The Sustainable Growth Rate (SGR) formula used for determining the conversion factor is fundamentally flawed, and so each year leads to a significant drop in reimbursement. Every year Congress acts at the last moment to reverse the drop. This year, if allowed to occur, the reimbursement rate will fall over 20%.

Congress may or may not permanently fix the SGR as part of “health care reform.” Some of us believe that the politicians don’t actually want to fix it because they raise huge amounts of money from the medical political action committees each year with the looming threat of whopping pay cuts. I wonder if anyone actually believes that Congress would cripple the health care system this year by removing all profit. To me, the whole process appears fundamentally dysfunctional.