CMS Continues to Evaluate Ophthalmic Office-Based Surgery Reimbursement

CMS Continues to Evaluate Ophthalmic Office-Based Surgery Reimbursement

The Office-Based Surgery (OBS) movement achieved a key milestone as CMS recognized OBS as an alternative option for cataract, glaucoma, and retinal eye surgeries with its inclusion in the 2023 proposed rule. Most importantly, the agency stated in the final rule that they will continue to evaluate these procedures in the non-facility setting and consider establishing non-facility codes in the future. Read more for office-based surgery reimbursement.

What Does This Mean for Current OBS Reimbursement?

There is no change to the current office-based surgery reimbursement as CMS continues its evaluation. Surgeons will continue to receive an enhanced professional fee from Medicare in lieu of a facility fee.   Changes in healthcare take time. The movement toward OBS may be long and arduous, but it is in motion and accelerating. The magnitude of supportive comments collected by CMS indicates that change is happening.

Thanks to all our physician partners in 80+ iOR Suites nationwide for their trailblazing efforts.  Their commitment to patient safety is what got us this far. It is more important than ever to remain diligent with data collection as we prepare for the 2024 proposed rule. For prospective surgeon partners who haven’t joined the movement, now is the time as your participation can perpetuate the shift forward. Bringing your cases to the office will expand the data showing safe and effective outcomes in the office setting.

Why Office-Based Surgery Reimbursement Was Not in the Final Rule

A transition to a new setting is disruptive and controversial. When cataract surgery transitioned from hospitals to ASCs, there was backlash and opposition. Office-based surgery is facing the same opposition with claims to detract progress.  In all, we have answers to their concerns, and in time, the movement will bear that out. The facts refute detractor claims.

Detractor ClaimsThe Facts
They’ve claimed the procedures may not be safe in the office.iOR Partners has a robust data reporting system that underlines the safety of OBS. Our peer-reviewed study will be published in the coming months.
They’ve claimed that accreditation and standards are necessary for Medicare to pay for OBS.iOR Partners is partnering with the accrediting bodies to align on national standards for OBS cataract surgery. iOR Suites already utilize the same recognized standards for surgical patient safety as ASCs and Hospitals.
They’ve claimed the OBS needs to have the exact same or higher standards as the ASC.OBS is being placed inside an already-licensed physician’s office with its own set of standards. iOR Partners created policies for iOR Suites based on the same recognized standards as ASC/Hospitals.
They’ve raised concerns over mild anesthesia vs. monitored sedation.Most office-based surgeries do not require that level of anesthesia and most patients prefer mild sedation.
They’ve claimed some patients have too many unmanaged comorbidities for OBS, assuming you as physicians are incapable of determining the best site of care for your cataract patients.The ophthalmologist and/or anesthesia provider will determine the required level of clearance needed for the type of anesthesia being performed based on the patient level of comorbidities and health history.  Over 40,000 ophthalmic procedures have been successfully performed in the office-based setting. 1,2

What Happens Next?

iOR Partners will continue to advocate for CMS to develop a consensus-driven plan to provide payment for these ophthalmic OBS procedures with key stakeholders including:

  • Continue meetings with congressional leaders to gain support on Capitol Hill.
  • Currently in discussions with AAO, ASCRS, AECOS, OMIC, The Joint Commission, and Quad A on standards for OBS.
  • Peer-Reviewed data supporting OBS safety, to be published in Q1 2023.
  • Urge CMS to request comparable peer-reviewed safety data from ASC organizations.
  • Meet with CMS in Q1/Q2 2023 in preparation for next year’s Proposed Rule.

The OBS movement has made a significant leap forward. iOR Partners will continue to lead the charge for office-based surgery reimbursement and advocate on behalf of our physician partners. Stay informed with our blog, so that iOR Partners can be a source of information on office-based surgery reimbursement. Please contact us if you have any questions on reimbursements.

  1. Ianchulev T, Litoff D, Ellinger D, Stiverson K, Packer M. “Office-Based Cataract Surgery.” Ophthalmology, Volume 123, Issue 4, P723-728, April 01, 2016.
  2. iOR occurrence data published quarterly from iOR Suites nationwide: