Sustainable Growth Rate, Glaucoma Shunt and Graft Procedures and Advocating in Washington State
Sustainable Growth Rate (SGR) Repealed and Replaced
On April 16, 2015, President Obama signed the Medicare Access and CHIP Reauthorization Act of 2015. This law permanently repealed and replaced the SGR formula and replaced with five years of 0.5% updates. This law maintains a fee-for-service option and consolidates the current quality reporting programs.
CMS’ Reversal of Reimbursement Policy on Donor Tissue for Glaucoma Shunt Graft Procedures
In April, the Centers for Medicare and Medicaid Services (CMS) issued a policy allowing for Ambulatory Surgical Centers (ASCs) to reimburse the cost of corneal allograft tissue used for coverage of a glaucoma aqueous shunt (CPT codes 66180, 66185). Recently, CMS issued a proposed rule that would reverse that policy; effective January 1, 2016 corneal tissue would no longer be carved out from the fee for the shunt cover procedure.
CMS did not change the pass-through for transplant tissue. In fact, the proposed rule specifically states that the reimbursement policy for transplant tissue would remain unchanged. ASCs should still reimburse the tissue separately using the V2785 code as they would for a corneal transplant (please note that sclera, pericardium, amniotic membrane and other tissues are not covered under this policy). Also be aware that the policy excludes Hospital Outpatient Departments as CMS felt that the fee for HOPDs adequately covered the cost of the materials. However, complaints from stakeholders (presumably those providing or using shunt covers other than cornea) led CMS to reconsider their recent policy change.
CMS is accepting public comment until August 31, and EBAA will vigorously oppose this reversal. To this end, we have prepared a brief survey to gather more information about how your eye bank prices sclera and cornea; tissue for shunt cover procedures. A similar survey will be sent to physicians to determine their costs and preferences among cornea, sclera, pericardium and amnion. We’re seeking pricing information because CMS’ rationale for the change is predicated in part on the relative cost of shunt cover alternatives, and we want to see if their assumptions are accurate.
Please visit https://www.surveymonkey.com/r/Shunt_Covers-Eye_Banks to complete the survey. Your responses will not be shared with anyone outside of staff and will be reported only in aggregate.
Join SightLife To Advocate For Improved Access to Care From Washington State Medicaid
SightLife’s mission is to eliminate corneal blindness worldwide. As part of this mission, patient access to high quality corneal tissue is paramount. SightLife routinely monitors trends in the provision of corneal tissue to assess any obstacles in access to tissue and life-changing transplants.
One trend we have been investigating is access to care for patients who are on Medicaid. Washington-based surgeons are concerned that patients enrolled under Medicaid programs in the state do not have access to appropriate care due to the reimbursement policies related to corneal transplantation and corneal tissue acquisition.
SightLife is leading an effort to engage Washington Apple Care on this issue to ensure patients have access to the latest surgical techniques and procedures. If you are interested in learning more about our efforts, please contact Rusty Kelly, Chief Marketing Officer at firstname.lastname@example.org.
Are you experiencing issues with reimbursement for corneal tissue or facilities allowing you to perform corneal transplant procedures?
SightLife has extensive resources that can assist you or your facility in overcoming reimbursement challenges. You can discuss your issue with Rusty Kelly, Chief Marketing Officer at email@example.com.