A Fair Assessment

The new year will see expanded taxonomy codes for retina specialists.

By Michael Jones, Senior Editor

Ophthalmic subspecialists have had difficulty being recognized through current coding structures. Under the original value-based reimbursement system developed by the Centers for Medicare and Medicaid Services (CMS), rather than being compared with practices in their own subspecialty, these doctors could be compared with more generalized ophthalmology practitioners, inadvertently favoring those physicians based on cost and resource use. In an interview with Retina Today, Michael X. Repka, MD, MBA, vice chair for clinical practice at the Wilmer Eye Institute, a professor of ophthalmology at Johns Hopkins Medical School in Baltimore, Md., and medical director for governmental affairs at the American Academy of Ophthalmology (AAO), discussed the increasing need for taxonomy classifications specific to ophthalmic subspecialties.

Access for Ophthalmology

For retina specialists, a customized taxonomy code allows more accurate representation of the field on a national level. As the effort to add these codes has only recently been successful for all interested subspecialties, Dr. Repka said, a lot remains to be seen in terms of how payors utilize these level 3 taxonomy codes and the potential impact on insurance networks moving forward. He identified areas of ambiguity that must be clarified, such as the application of taxonomy codes for multisubspecialty ophthalmologists.

“If they’re compared to comprehensive ophthalmologists, or even other subspecialists in ophthalmology, retina specialists could look very costly,” Dr. Repka said. “Yet, if you compare retina specialists with other retina specialists, then you have the right comparison.”

“The introduction of the new taxonomy codes involving ophthalmology ultimately comes down to providing ophthalmologists with access to a structure that has already been made available in many other areas of medicine,” Dr. Repka said. Prior to the introduction of the new program for ophthalmic subspecialties, which will take effect on January 1 for most codes, similar systems had already been put into place for specialties outside of ophthalmology. In addition to retina, several ophthalmic subspecialties will see new taxonomy codes, including glaucoma, neuro-ophthalmology, oculoplastics, pediatrics, and uveitis.1 Additionally, a new taxonomy code for cornea specialists will become available in April.1

Operational Effects

“The overall impact of the new taxonomy codes should be negligible in terms of the day-to-day operations of a practice,” Dr. Repka said. Depending on a facility’s electronic medical records system, each of the ophthalmic subspecialty codes can be submitted automatically; the exception to this, he explained, will be multisubspecialty doctors, whose codes could vary on a claim-by-claim basis. For example, subspecialists in both retina and uveitis may consider submitting separate claims within each of their applicable subspecialty designations.

“I think, from an operational point of view, there will probably be little to no impact on the physician, unless doctors were doing multiple subspecialties and wished to submit separate claims with separate subspecialty designations,” Dr. Repka said.

Additionally, he noted, the impact on practices will not be substantial at the start. As payors and physicians gain experience, the new codes allowing physician specialization could be used to help understand how an individual practice’s costs and resources stack up within the specialty, the subspecialty, and the entire medical community. Ophthalmology subspecialties, such as the average retina practice, may seem more expensive than comprehensive ophthalmology overall, but, within the subspecialty community, the price points should allow more reasonable comparisons. By allowing comparisons of subspecialists against their peers, the new taxonomy codes will provide a more accurate picture of individual practices. Dr. Repka reiterated, however, that these codes still need refinement with risk adjustment due to case severity mix, which cannot be done with this system. Additionally, he noted that payors will have a simple way to ensure that they have an adequate mix of subspecialists in their network.

Regulatory Concerns

The AAO collaborated with representatives of each of the subspecialties to generate the proposed new coding structure, which, on top of any financial factors and resources, will also act as a communication tool. The organizations involved included the American Society of Retina Specialists, the Retina Society, and the Macula Society. Taxonomy codes represent a self-selected designation, Dr. Repka noted; they are not a means of credentialing.

Although there was much discussion within the ophthalmology community regarding whether to pursue this decision, each subspecialty group eventually decided to approve moving forward after considering the idea. If taxonomy codes were to be used as a means of de facto credentialing, ophthalmology groups and subspecialty societies would advocate forcibly against the policy, Dr. Repka said.

“I don’t think it sets any precedent from a regulatory standpoint because these are voluntary and have existed in other specialties like otolaryngology and optometry for a long time,” he said, “and they haven’t presented any restrictions of practice” in those settings.

Why the Need?

Initially, there were no subspecialty designations within ophthalmology, leaving the cost of care in subspecialty practices to be compared with the general costs of care in ophthalmology in some cases. As there was no way to understand the value of subspecialist physicians from a digital perspective, insurance companies would remove subspecialists from panels for being too costly, not realizing their cost was driven by the mix of services they provided, Dr. Repka said. In some cases, specialty doctors would self-identify with payors, allowing more precise comparisons, while in other cases the subspecialty was removed from the comparison.

It is important for physicians of all backgrounds and specialties to have fair representation in their billing and reimbursement practices when compared with fellow physicians. The new structure allows physicians to identify which patients fall into a subspecialty on a case-by-case basis and thereby ensures a fairer assessment of costs. As these codes begin to be incorporated into claims and implemented by payors, it is important for retina specialists to be aware of the options available to them, Dr. Repka said.

1. Subspecialty Taxonomy Codes. American Academy of Ophthalmology. https://www.aao.org/practice-management/regulatory/mips/resource-use-taxonomy. Accessed November 8, 2017.


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Michael Jones
Senior Editor

Janet Burk

About New Retina MD

New Retina MD delivers cutting-edge content to retina specialists in their first 15 years of practice. Each issue provides fresh insight from younger physicians plus established mentors on clinical and nonclinical issues affecting ophthalmologists in the earlier stages of their careers. NRMD features surgical pearls, clinical research endeavors, practice management, medical reimbursement and policy, continuing educational requirements, financial planning, innovations, and more.