Proposed Medicare Physician Fee Schedule for 2012 Released

Proposed Medicare Physician Fee Schedule for 2012 Released-Confirms 30% SGR Payment Reduction
2012 ASC Rule with New Quality Reporting Program/Penalties Also Released

As expected, the proposed 2012 Medicare physician fee schedule – released today by the Centers for Medicare and Medicaid Services (CMS) – includes a 30 percent reduction in payments due to continuation of the flawed sustainable growth rate (SGR) formula. The ongoing, SGR-driven uncertainty around what physicians will be paid is bad for everyone involved. Tell your member of Congress that physicians need stability and a Medicare program partnership that they can rely on.

CMS anticipates that the conversion factor will be 23.96 in 2012, as compared to 33.97. The final rule due later this year may make significant changes to that amount, depending on what happens in any SGR legislation considered this year.

If the SGR cut is halted as in similar years, ophthalmology payments in general would increase by 2 percent in 2012, according to CMS.  As an example, the payment for cataract procedures (66984) would increase to $753.67 in 2012, up from a 2011 rate of $742.38.

Additionally, CMS has proposed that the AMA Specialty Society Relative-value Update Committee (RUC) do an extensive review of the Evaluation and Management codes, citing a belief that the work and intensity of those services when provided by primary care physicians has increased. Further, CMS is calling on the RUC to include several other high-volume services that have not been RUC reviewed since 2006. There are several eye codes on that list, including 66982 complex cataract, 92083 visual field and 92235 fluoroscein angiography.

Finally, the rule includes proposed quality and cost measures that would be used in establishing a new value-based modifier that would reward physicians for providing higher quality and more efficient care. There is one eye care related measure included:  Measure 13: Diabetes Eye Exam. The Affordable Care Act requires CMS to begin making payment adjustments to certain physicians and physician groups on Jan. 1, 2015, and to apply the modifier to all physicians, including ophthalmologists, by Jan. 1, 2017.

CMS has fact sheets available on the 2012 proposed rule.

Regarding the ASC rule and new quality reporting requirements, more details will follow in next week’s Washington Report Express. Note: the proposed ASC payment update for 2012 is 0.9 percent.

Notable Proposed Changes to PQRS and E-Prescribing

The Academy is pleased to announce that CMS has included a new Academy-advanced cataract measure group in the proposed 2012 schedule. Although ophthalmology was one of the top three performing specialties in the Physician Quality Reporting System (PQRS) in 2009, we have been working to improve success rates. We believe the measure group will facilitate greater ophthalmology success in 2012.The measure group includes:

  • Measure 191: Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery
  • Measure 192: Cataracts: Complications within 30 Days Following Cataract Surgery Requiring Additional Surgical Procedures
  • New: Cataracts: Improvement in Patient’s Visual Function within 90 Days Following Cataract Surgery
  • New: Cataracts: Patient Satisfaction within 90 Days Following Cataract Surgery

If the measure group is finalized by CMS, ophthalmologists who choose to report the group will qualify for the PQRS incentive by reporting the measure group for 30 patients over the course of the year. Final specifications for the group reporting will be available later this year.


Under current CMS rules, ophthalmologists are required to e-prescribe 25 times during the 2011 calendar year in order to avoid a 1.5 percent payment adjustment/penalty in 2013. CMS has announced changes to the 2013 and 2014 Medicare e-prescribing penalties that will allow physicians more time to avoid penalties in 2013 and 2014. CMS also proposes to include prescriptions electronically transmitted in conjunction with all Medicare Part B services provided during the reporting period, whether or not the service is included in the e-prescribing measure denominator. This change will allow surgeons who prescribe medications outside of the office visit to successfully e-prescribe.

CMS has also proposed to eliminate discrepancies in the system requirements for e-prescribing and meaningful use. Physicians with a certified electronic health record (EHR) system would be allowed to use their EHR system to e-prescribe and avoid future penalties, even if the certified EHR does not meet the CMS system requirements for the e-prescribing program. A similar change was proposed for 2012 e-prescribing earlier this year but has not been finalized.

If you have questions, contact the Academy’s Governmental Affairs office at 202.737.6662.