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Cataract Surgery Episode-Based Cost Measure: Key Tips for Ophthalmic Practices

As we have reported, the 2019 MIPS Cost category, which counts for 15% of the total MIPS score, will include a new episode-based cost measure for cataract surgery that will measure the total costs associated with providing cataract surgery. To help physicians and practices understand how they will be evaluated, ASCRS•ASOA is providing some key tips:

  • Only includes Part B claims with 66984. The measure only includes Part B patients and excludes Medicare Advantage patients and any complicated cataract surgery patients. Billing any other cataract CPT code, such as 66982, will exclude the patient from the measure.
  • Looks at costs associated with the surgery 60 days prior and 90 days following the procedure. Costs included in the episode are: the surgeon’s professional fee, the facility fee, anesthesia costs, pre-op testing, some drugs separately payable under Part B—including one administered during surgery that is currently under pass-through status—and additional post-operative care billed separately from the surgery, such as additional procedures resulting from a complication. A full list of the five included Part B drugs is available on the ASCRS•ASOA MACRA Center. Each year, the episode measures will be updated to include new Part B drugs on a case-by-case basis. ASCRS is also advocating that drugs on pass-through be excluded from the measure immediately.
  • Patients with ocular co-morbidities are excluded. Patients with significant ocular co-morbidities, such as glaucoma, macular degeneration, or diabetic retinopathy, are excluded. The list of exclusions is identical to the current exclusions for the quality measure 191: Cataracts, 20/40 or Better Visual Acuity 90 Days Following Cataract Surgery. These exclusions also ensure that a surgeon is not penalized for the additional cost of performing another surgery, such as MIGS, concurrently with cataract surgery.
  • The measure accounts for differences in cost based on the site of service. The measure only compares like surgeries to each other. Each surgery, or episode, is assigned to a sub-group based on the site of service, either ASC or hospital outpatient department (HOPD), and whether one (unilateral) or both eyes (bilateral) were operated on during the first eye’s global period. The sub-groups are ASC unilateral, ASC bilateral, HOPD unilateral, and HOPD bilateral.
  • Scoring is based on how likely, on average, a surgeon deviates from the expected cost of the surgery. Each sub-group is assigned an expected cost based on the national average. For example, a unilateral surgery in an ASC would have a lower expected cost than an HOPD unilateral surgery. CMS then compares the observed cost of each surgery, or episode, the surgeon performs and compares it to the expected cost of its sub-group. This comparison is done by dividing the observed cost of the episode by its expected cost, which expresses the observed cost’s deviation from the expected cost as a ratio. All the episodes’ ratios are added together, across all sub-groups, and divided by the total number of episodes to determine the total average of the surgeon’s episodes’ deviations from the expected costs. That figure is then multiplied by a national average total cost to represent the surgeon’s average deviation from expected costs as a dollar figure.
  • The Cost category still retains the problematic population-based measures total per capita cost and Medicare spending per beneficiary (MSPB). The MSPB measure is inpatient-based, so it is unlikely that an ophthalmologist would have it attributed, but he or she may be subject to the total per capita cost measure—in addition to the cataract episode-based measure. Each measure attributed is equally weighted. If both the total per capita and cataract episode measures are attributed to the physician, each will count for 50% of the Cost category score.

Additional information on the Cost category of MIPS is available on the ASCRS•ASOA MACRA Center. If you need assistance, please contact Allison Madson, manager of regulatory affairs, at or call the MACRA Hotline at 703-383-5724.


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