LAUSR

O phthalmologists, neurologists, and other specialist physicians rely on consultative care from neuroophthalmologists in the diagnosis and management of optic neuropathy, eye movement disorders, and other ophthalmic manifestations of systemic disease. These neuro-ophthalmic consultations are significantly more time consuming and complex than typical new patient encounters, involving the review of medical records and imaging studies from a number of providers, generation of a consultation report assisting in the coordination of care, as well as counseling patients regarding their disease. The additional effort required traditionally has been recognized through increased reimbursement and valuation of these services. In March 2006, the Office of the Inspector General deemed that throughout medicine, there was widespread inappropriate billing for consultative services; it was reported that 75% of consultations billed to Medicare in 2001 did not meet criteria for consultations, resulting in $1.1 billion of inappropriate payments (1). Subsequently, the Centers for Medicare and Medicaid Services (CMS) instituted a rule (Change Request 6,740) that took effect on January 1, 2010 and disallowed the submission of consultative current procedural terminology (CPT) codes for billing purposes in both inpatient and outpatient settings (2), resulting in a decrease in reimbursement (3). This action was predicted to have devastating consequences for neuro-ophthalmologists (4). Therefore, we analyzed recent (2014) Medicare claims data to assess the economic consequences as well as potential impact on patient care and access to neuro-ophthalmologic services by Medicare beneficiaries. When we examined new and return patient visit volumes and distributions for 68,078 family practitioners, 61,168 internal medicine specialists, 11,620 neurologists, and 12,375 ophthalmologists, we found that family practitioners and internists billed 2.9%–3.2% of visits as new patient encounters. Neurologists claimed 17.2%; ophthalmologists, 17.4%. By contrast, 113 neurology-trained North American Neuro-Ophthalmology Society (NANOS) members billed 24.5% of visits as new patient encounters, whereas 240 ophthalmology-trained members claimed 29.1%. Most (.83%) claims submitted by NANOS members were moderate-to-high complexity (CPT 99204, 99205), as were those claimed by all neurologists, all ophthalmologists, and internists (but not family practitioners). Thus, we found that neurologists and ophthalmologists claimed a greater percentage of new patient encounters with Medicare beneficiaries in 2014 than did primary care physicians; neuro-ophthalmologists from both specialties claimed an even greater proportion of such visits. Patients with new onset neuro-ophthalmic disease typically present to a general neurologist or comprehensive ophthalmologist for evaluation of symptoms; this physician will arrange for consultation with a neuro-ophthalmologist. Other subspecialists including neurosurgeons, physiatrists, otolaryngologists, and emergency physicians also commonly request neuroophthalmic consultations. It is uncommon that the neuro-ophthalmologist becomes the primary physician responsible for most or entirety of the patient’s medical care and typically remains in a consultative capacity. Business models in both ophthalmology and neurology demonstrate that many new patients are seen without a specific request from another medical provider (5,6). By contrast, most neuro-ophthalmologists require that new patients obtain a consultation request from an appropriate specialty physician to establish that a neuro-ophthalmic concern is present; this is not a specialty that typically has self-referred patients. In the past, consultation codes were reimbursed at a higher rate by CMS to acknowledge the additional time and effort required for patient evaluation. This practice embodied the concept of value-based payment, which is now being proposed as a “new” model of physician reimbursement. For example, in 2009, CPT 99204 was assigned 2.3 physician work–relative value units (wRVU), whereas Departments of Ophthalmology, Neurology, and Neurosurgery (PSS), University of Colorado Anschutz Medical Campus, Aurora, Colorado; Departments of Ophthalmology and Neurosciences (LPF), RutgersNew Jersey Medical School, Newark, New Jersey; and Department of Ophthalmology (VB), Emory University School of Medicine, Atlanta, Georgia.