MIPS: Two Significant Proposals Related To Ophthalmology

The Calendar Year 2025 Medicare Physician Fee Schedule (PFS) Notice of Proposed Rulemaking (NPRM) provides an overview of proposed policies for the 2025 performance year of the Quality Payment Program.

Quality Payment Program (QPP)

Prior to the launch of the Quality Payment Program (QPP) on January 1, 2017, payment increases for Medicare services were set by the Sustainable Growth Rate (SGR) law. This capped spending increases according to the growth in the Medicare population, and a modest allowance for inflation.

For the Quality Payment Program, CMS proposes six new, optional Merit-based Incentive Payment System Value Pathways for reporting beginning in 2025. CMS also solicits comments on whether to mandate MVP participation beginning with the CY 2029 reporting period.

New Ophthalmology MVP, Shake Up for Cataract Surgery MIPS

The 2025 proposed Quality Payment Program (QPP) rule has been announced and includes a few key adjustments that could change Merit-based Incentive Payment System (MIPS) reporting for ophthalmologists. The proposal comes with many similarities, some welcomed changes, and a few major adjustments.

Overall, there's little change in the foundational elements of the MIPS program; however, there are two significant proposals related to ophthalmology specifically, and that's the complete ophthalmic care MVP and then the revisions to the cataract surgery costs measures.

Among the many changes to the cataract cost measures was a new name, which would now read: Cataract Removal with Intraocular Lens (IOL) Implantation.

Additionally, the agency is adding new services to the attributive services lists, namely Dextenza (dexamethasone ophthalmic insert), Iheezo (chloroprocaine HCI ophthalmic gel), clinically relevant telehealth services, lenses, glasses and emergency visits for ocular complaints.

There are also several other changes made to diagnoses codes, with some removed and others changed to risk adjustment factors.

The second big ophthalmology proposal was the introduction of a MIPS value pathway (MVP). CMS has begun to seek feedback on this topic, including the sunsetting of traditional MIPS in favor of MVPs by 2029 or later.

The proposed title for the MVP would be Complete Ophthalmic Care.

Outside of these major changes, other smaller adjustments are being proposed to MIPS for 2025. There are anticipated adjustments in quality measures, namely the ability to remove unneeded measures and the breaking apart of optometry and ophthalmology in the specialty measure set.

Frequently Reported Activities For Ophthalmologists

For improvement activities, CMS is removing several frequently reported activities for ophthalmologists, including 24/7 access, population empanelment, specialist reports, and improvements for more timely test results. On the positive front, a new scoring methodology was proposed that levels the scoring for improvement activities. Additionally, a new methodology is being proposed for cost performance category scoring, which would eliminate deciles and replace them with benchmark ranges. This change would take effect for the current year.

Summary

Changes to #physician #reimbursement often stem from the budget neutrality requirement, which lacks a mechanism for inflationary adjustments. Disruptions occur when the value of specific services changes, affecting the reimbursement of other services to maintain budget neutrality. CodeToolz is committed to providing up to date coverage of changes in #Medicare and commercial payer fee schedules, the impact on physicians, and analyses on the fees used to pay doctors.

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