The New CPT Orthoptic Code #92066 – Part 2

I’m writing this because I saw some information online this morning about “RVUs” and their impact on reimbursement rates for CPT codes 92065 and 92066 that warrant elaborating. More on that in a moment.

I indicated in Part 1 that it should be the goal of speciality practice to render services independent of insurance systems so that the primary relationship can be maintained between the service provider and the patient without having to compromise care based on the whims and dictates of third party carriers. Vision therapy practices have increasingly done this, progressively modeling the success of patient self-pay in orthodontia case fees. Parenthetically, primary care practices specializing in myopia control have adopted the model of fee for service independent of insurance reimbursement, modeled after the success of patient self-pay for refractive surgery in Ophthalmology. Having said this, some practices like to remain conversant with third party reimbursement profiles so that they can serve as advocates for the patient who has paid the office in full to be reimbursed to the extent that the carrier provides for out-of-network services.

The American Optometric Association has a Third Party Center that works tireless in advocacy efforts, which encompasses the Coding and Reimbursement Committee. The document that I shared in Part 1, Vision Therapy and Neuro-Rehabilitation:
Optometric Considerations in Third Party Reimbursement
, was a collaborative efforts spearheaded by our New Jersey colleague Dr. Harvey Richman with significant input from another NJ colleague, Dr. Charles Fitzpatrick as well as the AOA Coding and Reimbursement Committee chaired by Dr. Rebecca Wartman. The document is based in part on Chapter 10 of a COVD members-only monograph, “How to Build a Successful Vision Therapy Practice”.

What I wrote about at the outset of Part 1, but didn’t elaborate on, was that the concept of the RVU or Relative Value Unit, which will ultimately determine how much a carrier reimburses for each CPT procedure. The AOA document, on page 13, notes the following: “Each session utilizing therapeutic procedures or services, whose definition does not include specific time requirements, must still have the face-to-face time between the patient and physician or licensed therapist documented. In the case of therapeutic services 92065 it is valued by the CMS Relative Value Committee based on physician time per session and limited to one session per day. Some carriers do allow for multiple units to be submitted on the same day, but documentation and medical necessity must warrant.” So in anticipating what you’ll get paid, or what the patient will be reimbursed for regarding VT services in 2023 it may help to better understand who RVUs factor into the equation.

If you learn best from video, here is a nice pithy clip to introduce you to RVUs.

If you learn better in print, there is a nice online primer from the AAPC (American Academy of Professional Coders about RVUs, which explains that there are three components to the RVU:

  • Work RVUs (wRVUs) account for the provider’s work when performing a procedure or service. Variables factored into this value include technical skills, physical effort, mental effort and judgement, stress related to patient risk, and the amount of time required to perform the service or procedure. wRVUs account for 50.866% of the total RVU for a code.
  • Practice expense (PE) RVUs reflect the cost of clinical and nonclinical labor and expenses of the practice. These include medical supplies, office supplies, clinical and administrative staff, and pro rata costs of building space, utilities, medical equipment, and office equipment. PE-RVUs account for 44.839% of the total RVU for a given service.
  • Malpractice (MP) RVUs reflect the cost of professional liability insurance based on an estimate of the relative risk associated with each CPT® code. mRVUs account for 4.295% of a service’s total RVUs.

The prior wRVU for CPT Code 92065 was very low, at 0.37, and based on input from AOA to the RVS Update Committee (RUC) it has increased to 0.71 this year. But realize, as noted above that this represents only part of the total RVU. With the addition of the practice expense and malpractice components, the new total value will be 1.22 RVU for 2023.

So what’s the bottom line? Every year Medicare (CMS) establishes a conversion factor, and for 2023 it is $33.06. That number gets multiplied by the total RVU, so for the doctor code 92065 that means you (or the patient) is going to get reimbursed a total of $40.33 (1.22 x $33.06) per session.

In 2023, the technician code 92066 will have an RVU of 0.77. You (or the patient) is going to get reimbursed $25.46 (0.77 x $33.06) per session.

The AAPC website has a handy-dandy wRVU calculator. It hasn’t been updated yet for 2023 (that usually happens in February), but if you plug in any CPT code it will give you the wRVU. The figure currently listed is the 2022 value of 0.37 for code 92065, and 92066 doesn’t appear yet.

One reason I’m mentioning this is that I’ve seen suggestions in social media to use CPT code 92499 (unlisted ophthalmological service) together with 92065 (or now 92066). As you’ll see, when you plug 92499 into the calculator you get a wRVU of 0.0, so caveat emptor.

Using the calculator, you can get a rough idea of what to expect. For example (2022 value), the Rehab code 97112 (neuromuscular re-education) had a wRVU of 0.50. The E/M visit doctor code 99212 had a wRVU of 0.70. The ophthalmic intermediate exam doctor code 92012 had a wRVU of 0.92. The more complexity reflected in the code, the greater is the wRVU. For example, if 99213 is indicated instead of 99212, it bumps up the wRVU to 1.30. Naturally, the documentation in the patient record has to justify the level of coding used.

There is one other component that modifies the paycheck amount, and that is a geographic fee adjustment. As the video above notes, the reimbursement for a given code in San Francisco is going to be higher than in rural Kentucky.

What your colleagues are asking about coding might help you

If you’re an AOA member, you can pose questions directly to their coding experts.

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