- Email: [email protected]
Billing of cataract surgery as complex versus routine for Medicare beneficiaries
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ARTICLE
Billing of cataract surgery as complex versus routine for Medicare beneficiaries Sidra Zafar, MD, Peiqi Wang, MD, Divya Srikumaran, MD, Oliver D. Schein, MD, MPH, Jennifer E. Thorne, MD, PhD, Martin A. Makary, MD, MPH, Fasika A. Woreta, MD, MPH
Purpose: To estimate ophthalmologist-level variation in cataract surgery billing and evaluate patient and ophthalmologist characteristics associated with complex cataract surgery coding. Setting: Cross-sectional study. Design: Retrospective case series. Methods: Medicare beneficiaries aged 65 years or older who had cataract surgery between January 1, 2016, and December 31, 2017, were included. Billing of cataract surgery as complex versus routine and patient and physician characteristics associated with billing of cataract surgery as complex were evaluated. Results: An estimated 3.5 million cataract procedures were performed on Medicare beneficiaries in 2016 and 2017. Men (odds ratio [OR], 1.79; 95% confidence interval [CI], 1.75-1.82), patients 75 years or older (versus those aged 65 to 74 years: OR, 1.35; 95% CI, 1.33-1.36), and racial minorities (blacks versus whites:
C
ataract surgery is the most commonly performed surgical procedure in the United States,1,2 and at least 80% of cataract surgery in the U.S. is performed on Medicare beneficiaries.1,3 It is estimated that the Medicare program spends more than $3.4 billion annually treating cataracts.4 As the U.S. population of older adults continues to expand, healthcare expenditures on cataract surgery are expected to rise further.5 One variable cost associated with cataract surgery is the upcoding of the operation as complex based on the use of devices or techniques not usually used in routine cataract surgery (eg, iris-expansion device, suture support for intraocular lens, or use of trypan blue). The incidence of cataract operations billed as complex nearly doubled between 2005 and 2009,6 and the rate has increased faster among minorities.7 As cataract surgery rates continue to rise in the U.S. and Medicare spending continues to outpace overall
OR, 1.80; 95% CI, 1.75-1.85) had increased odds of having cataract surgery coded as complex. The mean rate of coding for complex cataract surgery by individual surgeons (n Z 10 075) in the United States was 11.2%, with significant variation. A high-risk clinical diagnosis code was associated with 40.0% of complex cataract surgeries. Adjusted for patient characteristics, ophthalmologists who graduated from medical school within the past 10 years (OR, 1.35; 95% CI, 1.22-1.49) were more likely to code for complex cataract surgery. Higher volume ophthalmologists were less likely to code for complex cataract surgery than low-volume ophthalmologists.
Conclusions: There was marked variation among ophthalmologists in the use of complex cataract surgery. Some variability might represent inaccurate coding and was not entirely based on differences in referral patterns for more complex patients. J Cataract Refract Surg 2019; 45:1547–1554 Q 2019 ASCRS and ESCRS
Supplemental material available at www.jcrsjournal.org.
economic growth,8 a better understanding of the factors associated with complex billing could help inform efforts to improve coding compliance and reduce avoidable healthcare costs. Although previous studies have suggested this trend toward increased use of complex cataract coding, they have relied on a 5% sample of claims.7 Using 100% of Medicare outpatient claims, we designed a study to assess patient-level and ophthalmologist-level characteristics associated with variations in coding for complex cataract surgery in the U.S. MATERIALS AND METHODS Study Design and Population The Institutional Review Board, Johns Hopkins University School of Medicine, approved this retrospective cross-sectional analysis of 100% Medicare fee-for-service carrier claims accessed from the Centers for Medicare & Medicaid Services. All Medicare beneficiaries 65 years or older who had routine or complex cataract
Submitted: April 3, 2019 | Final revision submitted: June 12, 2019 | Accepted: June 13, 2019 From the Department of Ophthalmology (Zafar, Srikumaran, Schein, Thorne, Woreta), Wilmer Eye Institute, the Department of Surgery (Wang, Makary), Johns Hopkins University School of Medicine, the Department of Epidemiology (Thorne), and the Department of Health Policy and Management (Makary), Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA. Corresponding author: Fasika A. Woreta, MD, MPH, 600 N Wolfe St, Johns Hopkins University, Baltimore 21287, MD. Email: [email protected]. Q 2019 ASCRS and ESCRS Published by Elsevier Inc.
0886-3350/$ - see frontmatter https://doi.org/10.1016/j.jcrs.2019.06.008
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surgery (in 1 or both eyes) between January 1, 2016, and December 31, 2017, were identified based on Current Procedural Terminology (CPT) codes 66984 (routine cataract surgery) and 66982 (complex cataract surgery). Cataract surgery is considered complex if the procedure involves one or more of the following: a dye for staining the anterior capsule, use of an iris-expansion device, use of a capsular tension ring, or suture fixation of an intraocular lens. In all beneficiaries with CPT code 66982, high-risk clinical comorbidities that might qualify the surgery as complex were identified using the International Classification of Diseases (ICD), 10th Revision, clinical modification (ICD-10-CM) diagnosis codes (Table S1, available at http://jcrsjournal.org). Patient Characteristics Patient-related information on age, sex, race, and residential ZIP code was obtained from the Medicare Master Beneficiary Summary File. The ZIP code was mapped to a Federal Information Processing Standard (FIPS) code using the sashelp.zipcode file (SAS, Inc.) and to a core-based statistical area (CBSA) code using a National Bureau of Economics FIPS to CBSA crosswalk to determine the region and type of residence. Based on the place of the service code available on each claim, the procedural setting was categorized into outpatient, ambulatory surgery center, and other. Ophthalmologist Characteristics National provider identifier numbers were available on each claim for identification of the ophthalmologist performing cataract surgery. Surgeon characteristics were obtained from Medicare Data on Provider Practice and SpecialtyA and Physician Compare National Downloadable File.B Characteristics of interest included sex, years since graduation from medical school, primary specialty, practice region and location, and the volume of cataract surgery. The surgeon-level rate of complex cataract surgeries was calculated for ophthalmologists who performed more than 10 cataract surgeries during the study period. Based on the U.S. distribution of this surgeon-level metric, a cutoff of the mean plus 2 times the standard deviations (SDs) was defined for identification of surgeon outliers with high use of complex cataract surgeries. Statistical Analysis Patient characteristics are presented by whether they were billed as a routine versus a complex cataract surgery, and ophthalmologist characteristics are presented by their outlier status. Two-sample t tests were used to compare continuous variables and Pearson chisquare tests to compare categorical variables. A multivariable logistic regression model was fitted using generalized estimating equations to evaluate factors associated with the use of complex cataract surgery codes. The outcome event modeled was coding for a complex cataract surgery. The covariates included patient-level characteristics (age, sex, race, region and type [urban versus rural] of residence, procedural setting, and presence of high-risk clinical diagnosis) and ophthalmologistlevel characteristics (sex, years in practice, and mean annual cataract surgery volume). This model was clustered at the ophthalmologist level and accounted for the correlation of eyes within the same patient for bilateral cases as well as the correlation of patients within the same physician. All statistical analyses were performed using SAS Enterprise software (version 7.1, SAS, Inc.). The significance level was set at a P value less than 0.05.
RESULTS Patient Characteristics
Of the 3 500 891 cataract operations on Medicare beneficiaries in 2016 and 2017, 302 155 (8.6%) were coded as complex. The median age of patients having cataract surgery coded as routine or complex was 73.9 years and 76.5 years, respectively. Male patients and black patients Volume 45 Issue 11 November 2019
had a significantly higher proportion of cataract surgeries coded as complex versus routine (both P ! .0001) (Table 1). On multivariate analysis (Table 2), patient characteristics that were independently associated with the use of complex cataract surgery included age older than 75 years compared with age 65 to 74 years and non-white race compared with white. Black patients’ odds of complex cataract surgery were almost twice as high as that of white patients, and North American Native patients’ odds were 1.58-fold higher than that of white patients. Women were less likely to have a complex cataract than men. Cataract surgeries performed in outpatient hospital settings were more likely to be billed as complex than those performed at an ambulatory surgery center. Ophthalmologist Characteristics
During the study period, 10 075 ophthalmologists performed more than 10 cataract surgeries. The median cataract surgery volume was 229 surgeries (range 11 to 7920) over the 2-year study period, with 2500 ophthalmologists (31.0%) performing 226 or more surgeries (Table 3). Figure 1 shows the state-level variation in complex cataract surgery rates. The highest rates were predominantly in the Midwestern and Northeastern states of New York (13.8%), New Jersey (13.0%), Iowa (12.9%), Connecticut (11.7%), and Massachusetts (11.2%). The overall mean surgeon-level rate of coding for complex cataract surgery was 11.2% (median 7.9%; range 0% to 100%). There was marked variation in surgeon-level use of the complex cataract surgery code (Figure 2). Most cataract surgeons (5999 [59.5%]) had a complex rate of 10% or less. A complex cataract cutoff rate greater than 2 SDs above the mean (95th percentile for use of complex cataract codes) (rate Z 35%) identified 459 (4.6%) outlier surgeons. Complex cataract procedures made up 8.3% of an inlier’s total case volume and 60.7% of an outlier’s total case volume. On multivariate analysis (Table 2), ophthalmologists who graduated within the past 10 years were more likely to code cataract surgeries for patients as complex. Although not statistically significant, a similar trend for was also observed for female ophthalmologists compared with male ophthalmologists. Finally, higher-volume ophthalmologists were less likely to code cataract surgery as complex than ophthalmologists in the lowest quartile with respect to their annual cataract surgery volume (Table 2). Clinical Comorbidities
Of the 302 155 cataract surgeries coded as complex, 120 862 (40.0%) had an associated high-risk clinical diagnosis. Pupil-related abnormalities were most common 64 927 (21.5%) followed by floppy-iris syndrome 35 626 (11.8%) and mature cataracts 25 864 (8.6%). As the proportion of cataract surgeries coded as complex increased, the ophthalmologist-level proportion of patients with any high-risk clinical diagnosis also rose. However, a discrepancy was noted at the ophthalmologist level for complex cataract coding and the percentage of patients
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Table 1. Characteristics of patients billed for routine versus complex cataract surgery. Cataract Surgery Characteristic Age (y) Median Min, max Age group, n (%) 65–74 y 75–84 y 85–94 y R95 y Sex, n (%) Male Female Race, n (%) White Black Asian Hispanic North America native Other or unknown Residence, n (%) Urban Rural Region, n (%) Midwest Northeast South West Other† Setting, n (%) ASC Outpatient hospital Otherz High-risk eye condition, n (%) POAG, n (%)
Routine (n Z 3 198 736)
Complex (n Z 302 155)
73.9 65.0, 106.3
76.5 65.0, 109.2
1 822 102 (57.0) 1 167 419 (36.5) 204 728 (6.4) 4 487 (0.1)
128 692 (42.6) 128 082 (42.4) 43 388 (14.4) 1 993 (0.7)
1 224 900 (38.3) 1 973 836 (61.7)
171 942 (56.9) 130 213 (43.1)
2 806 267 (87.7) 184 433 (5.8) 56 099 (1.8) 41 286 (1.3) 15 357 (0.5) 95 294 (3.0)
247 364 (81.9) 29 883 (9.9) 7 652 (2.5) 5 541 (1.8) 1 849 (0.6) 9 866 (3.3)
2 875 709 (89.9) 323 027 (10.1)
273 958 (90.7) 28 197 (9.3)
728 720 (22.8) 515 855 (16.1) 1 276 718 (39.9) 663 342 (20.7) 14 101 (0.4)
70 037 (23.2) 68 373 (22.6) 105 990 (35.1) 56 408 (18.7) 1 347 (0.5)
2 299 205 (71.9) 827 390 (25.9) 72 141 (2.3) 32 522 (1.0) 113 903 (3.6)
195 065 (64.6) 98 011 (32.4) 9 079 (3.0) 120 951 (40.0) 16 247 (5.4)
P Value* !.0001
d
!.0001
!.0001
!.0001
!.0001
!.0001
!.0001 !.0001
ASC Z ambulatory surgery center; POAG Z primary open-angle glaucoma *Continuous variables compared using independent 2-sample tests and categorical variables using chi-square tests † Included Alaska, Puerto Rico, Virgin Islands, Guam, Northern Mariana Islands z Included office, inpatient hospital, and unassigned type of setting
served with any high-risk diagnosis. For example, of ophthalmologists whose complex cataract surgeries accounted for more than 50% of their surgical volume, the median percentage of high-risk patients ranged between 9.3% and 42.2% (Table 4). DISCUSSION Although the surgeon-level rate of coding for complex cataract surgery in the U.S. was 11.2%, the coding rate by surgeon varied widely (range 0% to 100%). Complex cataract surgery rates also varied between states. We found highrisk clinical diagnoses that might warrant complex cataract extraction were present in only 40% of the cataract surgeries coded as complex, with pupil-related abnormalities being the most common diagnosis. Men, racial minorities, and patients treated at outpatient hospitals were more likely to have their cataract procedure billed as complex. Among ophthalmologists, fewer years since medical school
graduation and a low cataract surgery volume were independently associated with an increased use of complex cataract codes. We also queried coding data for cataract surgery at our institute, a tertiary care center that caters to a large population of referred patients, and found the proportion of complex cataract procedures among 36 ophthalmologists to range from 0.0% to 33.9%, with an overall rate of 11.3% in 2018. Thus, considering that some ophthalmologists (2.7% of total population) were coding for complex cataract surgery as much as 91% to 100% of the time, we believe this variability in cataract coding at a national level is unlikely to be explained solely by differences in referral practice patterns for more complex patients. Financial motivation could be a reason for the variation in the use of complex cataract surgery codes. A study by Gong et al.6 that analyzed Medicare data between 2005 and 2009 found that for every 1.0% decrease in Medicare Volume 45 Issue 11 November 2019
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Table 2. Patient and ophthalmologist characteristics associated with use of complex cataract surgery codes. Characteristic
Adjusted OR
95% CI
P Value*
Ref 1.35 2.31 4.64
d 1.33, 1.36 2.26, 2.35 4.31, 4.99
d !.0001 !.0001 !.0001
Ref 0.56
d 0.55, 0.57
d !.0001
Ref 1.80 1.42 1.33 1.58 1.12
d 1.75, 1.85 1.37, 1.48 1.27, 1.38 1.45, 1.73 1.09, 1.15
d !.0001 !.0001 !.0001 !.0001 !.0001
0.99 1.06 Ref 1.02 0.78
0.93, 1.06 1.00, 1.12 d 0.96, 1.08 0.58, 1.05
.75 .07 d .57 .10
Ref 1.01
d 1.00, 1.03
d .13
Ref 1.20 1.28
d 1.16, 1.25 1.16, 1.42
d !.0001 !.0001
5.1, 76.8 d
!.0001 d
Ref 1.03
d 0.95, 1.12
d .48
1.35 0.93 0.93 Ref
1.22, 1.49 0.83, 1.05 0.84, 1.04 d
!.0001 .23 .20 d
Ref 0.88 0.90
d 0.80, 0.97 0.82, 0.99
d .01 .03
Patient Age group 65–74 y 75–84 y 85–94 y R95 y Sex Male Female Race White Black Asian Hispanic North America native Other or unknown Region Midwest Northeast South West Other Residence Urban Rural Procedure setting ASC Outpatient hospital Other High-risk clinical diagnosis Yes No Ophthalmologist Sex Male Female Years since medical school graduation 0–10 11–20 21–30 R31 Mean annual cataract surgery volume 1st quartile: %50 2nd quartile: 51–115 3rd quartile: 116–225
86.6 Ref
CI Z confidence interval; OR Z odds ratio; Ref Z reference *P ! .05
payment for complex cataracts, there was a 1.12% increase in the complex cataract service volume. They observed that the volume for complex cataract services more than doubled during the studied time frame. No similar trends were noted for noncomplex cataract service volume.6 Another potential source of practice variation might be related to surgeon training, with attending surgeons in teaching institutions more likely to use additional resources, such as trypan blue, when teaching residents.9 However, unless clinically indicated, it is not appropriate
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to upcode such cases. Finally, some of the variation likely reflects misunderstanding of the billing regulations. It is important that surgeons understand such regulations to avoid inadvertent billing errors and the potential for fraud. Newly graduating physicians in particular are increasingly cognizant of gaps in their knowledge of proper documentation and coding,10 and studies have found physicians in a variety of disciplines reporting the need for additional formal training in billing and coding.11–13 Including training on billing and coding during medical education
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Table 3. Characteristics of ophthalmologists with complex cataract rate less than 35% versus 35% or greater.* Characteristic Sex, n (%) Male Female Years since medical school graduation Median Min, max Number (%) 0–10 11–20 21–30 R31 Unknown Practice region, n (%) Midwest Northeast South West Otherz Practice location, n (%) Urban Rural Unknown Mean annual cataract surgery volume Median Min, max Number (%) 1st quartile: %50 2nd quartile: 51–115 3rd quartile: 116–225 4th quartile: R226
Complex Cataract Rate <35% (n Z 9616)
Complex Cataract Rate R35% (n Z 459)
7520 (78.2) 2096 (21.8)
321 (69.9) 138 (30.1)
25 0, 62
23 2, 58
1291 (13.4) 2169 (22.6) 2615 (27.2) 3121 (32.5) 420 (4.4)
88 (19.2) 102 (22.2) 92 (20.0) 161 (35.1) 16 (3.5)
2070 (21.5) 2052 (21.3) 3244 (33.7) 2130 (22.2) 120 (1.3)
81 (17.7) 165 (36.0) 129 (28.1) 80 (17.4) 4 (0.9)
9424 (98.0) 177 (1.8) 15 (0.2)
454 (98.9) 3 (0.7) 2 (0.4)
120 6, 3960
42 6, 983
2293 (23.9) 2385 (24.8) 2462 (25.6) 2476 (25.8)
255 (55.6) 126 (27.5) 54 (11.8) 24 (5.2)
P Value† .001
.75
!.0001
.06
!.0001
*Cutoff for identification of high utilizers calculated as mean C 2 SD of national physician distribution, corresponding to R95th percentile † Continuous variables compared using independent 2-sample tests and categorical variables using chi-square tests z Included Alaska, Puerto Rico, Virgin Islands
might increase proficiency in basic coding and billing skill.14 Healthcare-related waste continues to be an endemic problem, comprising up to 30% of all medical spending
and accounting for an estimated $210 billion in excess spending each year.15 In particular, physician-level clinical variation remains a major barrier to quality improvement, and the use of physician-level instead of hospital metrics
Figure 1. State-level rate of complex cataract procedures in 2016 and 2017 in the United States.
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Figure 2. Distribution of ophthalmologistlevel rate of complex cataract procedures in 2016 and 2017 in the United States.
has been proposed to encourage changes in physician behavior.16 Findings in large-scale peer comparison studies reported reductions in inappropriate antibiotic prescribing rates and in operative costs by 5%17 and 7%,18 respectively, when physicians were notified of their practice patterns. Previous studies19–21 have shown that geographic variation in several parameters related to cataract surgery, including in the age of patients at initial cataract surgery, duration from initial cataract diagnosis to first surgery, and state-level cataract surgery rates. The interstate variation in coding for complex cataract surgery rates likely reflects some combination of local distribution of patient and provider characteristics. Possible explanations that have been postulated include variations in a patient’s motivation for surgery, differences in eyecare professional availability, and the assertiveness of ophthalmologists in recommending surgery. Socioeconomic status, the number of optometrists per 100 000 residents, and joint management of cataract surgery by ophthalmologists and
optometrists have also been found to be associated with variations in regional cataract surgery rates.20,22,23 Erie et al.23 found that the lowest joint management rates of cataract surgery were in the Northeast and Southwest regions of the U.S. (regions with higher use of complex cataract surgery codes in our study). The highest rates were in the Southeast and Midwest (regions with lower use of complex cataract surgery codes in our study). However, additional research would be needed to explore the underlying causes for the geographic variation in the use of complex cataract surgery codes that we observed.23 We hypothesize that the patient-level differences we identified for complex cataract coding might have been attributable to underuse of and/or delayed access to appropriate ophthalmic care in these patient populations, leading to more mature cataracts at presentation. Multiple studies from high-income countries, including the U.S., have consistently shown men to have significantly lower rates of eyecare use than women.24–29 In the study by
Table 4. Cataract surgeries coded as complex and proportion of patients with high-risk clinical diagnosis at the level of the ophthalmologist. Ophthalmologist-Level: Patients with Any High-Risk Diagnosis (%) Complex Procedures 0% 1%–10% 11%–20% 21%–30% 31%–40% 41%–50% 51%–60% 61%–70% 71%–80% 81%–90% 91%–99% 100%
Physicians (n)
Mean ± SD
Median
IQR
Min, Max
679 5320 2565 885 324 165 59 29 14 8 16 11
2.7 G 13.2 2.7 G 6.7 7.4 G 10.4 11.2 G 12.4 14.3 G 14.2 19.2 G 20.0 20.8 G 22.9 29.6 G 27.9 32.1 G 33.8 42.5 G 38.8 24.5 G 33.5 38.3 G 44.4
0.0 0.8 5.5 7.6 9.4 10.9 9.3 23.9 18.1 42.2 9.3 20.7
0.0, 0.0 0.0, 3.6 0.2, 11.7 0.3, 19.8 0.6, 26.7 0.5, 37.2 0.0, 48.7 1.5, 46.2 0.0, 70.2 2.5, 80.0 1.3, 24.7 0.0, 90.4
0.0, 100 0.0, 100 0.0, 100 0.0, 100 0.0, 78.6 0.0, 98.9 0.0, 69.4 0.0, 95.0 0.0, 77.2 0.0, 90.5 0.0, 100 0.0, 100
IQR Z interquartile range
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Mahr et al.,7 men were almost twice as likely as women to have a small pupil–related ICD-9-CM diagnosis in association with a complex cataract surgery code, which was attributed to the higher use of a-adrenergic receptor antagonists in men.7 Similarly, studies that have evaluated disparities in eyecare access and use in the U.S.27,30–32 found race to be a significant variable in eyecare uptake across all age groups. In the Baltimore Eye Survey,33 black participants were 5 times more likely than white patients to have an unoperated cataract. In the Los Angeles Latino Eye Study,34 35% of all Hispanic participants who needed cataract surgery had not had the procedure. Last, Winter35 found that Medicare patients treated at ambulatory surgery centers, including those having cataract removal, were on average medically less complex than patients receiving similar procedures in hospital outpatient departments. Hence, we suggest that because of their associated medical comorbidities, these patients might be more likely to have surgery later, leading to more advanced cataracts at presentation. Significant variations can exist among graduating residents not only with respect to their overall surgical volume but also in respect to their surgical exposure to complex cataract cases. We hypothesize that younger surgeons with limited experience might therefore have a lower threshold for the use of trypan blue and/or instruments to facilitate complex cases compared with surgeons who have been in practice for longer; the same might be true for low-volume surgeons. A study by Puri et al.9 that assessed resident cataract surgery performed under supervision of a novice attending surgeon found significantly increased use of trypan blue by the novice surgeon compared with a surgeon with more than 11 years of clinical experience. The authors argued that the greater use of trypan might have reflected the novice surgeon’s desire to facilitate the surgery and might not necessarily have been correlated to the level of cataract. Albeit not statistically significant, we also found a trend toward higher use of complex cataract surgery codes by female surgeons than by their male counterparts. There is evidence from other branches of medicine that men and women might practice medicine differently,36,37 and sexbased differences in annual cataract surgery volumes are known to exist in ophthalmology.38 It would be of interest to explore additional differences that might exist between female and male ophthalmologists in their practice patterns and resource use across a variety of ophthalmic interventions. Moreover, although women compromise almost 30% of the ophthalmologist workforce with 10 years or less of experience, they account for only 18% and 11% of the workforce with more than 10 and 30 years of experience, respectively.C Our findings should be considered in the context of an important limitation. Our study could not account for actual patient clinical findings or referral bias at a granular level. It is likely that some surgeons care for more complex patients and would be expected to code cataract surgeries as complex at rates higher than the national mean. However, we doubt that such differences in patient populations would account
for the range in “coding as complex” that was observed or for the finding of higher rates among lower volume surgeons. Furthermore, our study population was Medicare fee-for-service beneficiaries and might not be generalizable to Medicare Advantage beneficiaries. In addition, because of the limitations of the type of data available in a Medicare claims database, our study was unable to adjust for factors, such as practice setting or subspecialty. Finally, our study was limited to patients 65 years or older, which limits the generalizability of our findings to younger patients. These limitations withstanding, our study was based on 100% capture Medicare carrier claims, which allowed for evaluation of a large, diverse group of individuals receiving care in different settings across the U.S.39 Also, because more than 80% of all cataract surgery is covered by Medicare, trends among Medicare beneficiaries can be considered a barometer of national trends.3 The Improving Wisely collaborativeD uses national data to identify overuse patterns for various diagnostic, medical, and surgical procedures. In the Improving Wisely model, an overuse metric is developed by expert consensus and Medicare data are queried to identify physician outliers and inliers.14 Confidential, benchmarked, personalized audit, and feedback data reports are shared with physicians to change physician behavior and reduce overuse and cost waste. Such an approach is a possible mechanism to address avoidable excess costs associated with inappropriate upcoding. Knowing where one stands in comparison to peers might assist in education and self-regulation. In conclusion, we found substantial variability in the rate at which eye surgeons code for complex cataract surgery. That variability is not likely explainable based on differences in referral practices for more complex patients. Inaccurate use of the code for complex surgery is common and likely reflects some combination of misunderstanding of the intent of the code and financial incentive. Cataract surgeons should take a more proactive approach to address the wide variation in complex cataract surgery rates and help to create consensus physician-level metrics. Such physicianspecific and physician-endorsed metrics can subsequently be presented in peer comparison reports to provide actionable feedback to physicians with outlier practice patterns.
WHAT WAS KNOWN Racial minorities have significantly higher rates of complex cataract surgery than white Medicare beneficiaries.
WHAT THIS PAPER ADDS There was large variation in the use of complex cataract surgery codes among ophthalmologists and between states. An associated high-risk clinical diagnosis was present in fewer than one half of all surgeries coded as complex. Ophthalmologists who graduated within the past 10 years from medical school were more likely to code cataract surgery as complex, whereas higher volume ophthalmologists were less likely to code cataract surgery as complex.
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REFERENCES 1. Erie JC, Baratz KH, Hodge DO, Schleck CD, Burke JP. Incidence of cataract surgery from 1980 through 2004: 25-year population-based study. J Cataract Refract Surg 2007; 33:1273–1277 2. Klein BEK, Howard KP, Lee KE, Klein R. Changing incidence of lens extraction over 20 years; the Beaver Dam Eye Study. Ophthalmology 2014; 121:5–9 3. French DD, Margo CE, Behrens JJ, Greenberg PB. Rates of routine cataract surgery among Medicare beneficiaries [research letter]. JAMA Ophthalmol 2017; 135:163–165 4. Brown GC, Brown MM, Menezes A, Busbee BG, Lieske HB, Lieske PA. Cataract surgery cost utility revisited in 2012; a new economic paradigm. Ophthalmology 2013; 120:2367–2376 5. The Eye Diseases Prevalence Research Group. Prevalence of cataract and pseudophakia/aphakia among adults in the United States. Arch Ophthalmol 2004; 122:487–494 6. Gong D, Jun L, Tsai JC. Trends in Medicare service volume for cataract surgery and the impact of the Medicare physician fee schedule. Health Serv Res 2017; 52:1409–1426 7. Mahr MA, Hodge DO, Erie JC. Racial/ethnic differences in rates of complex cataract surgery among United States Medicare beneficiaries. J Cataract Refract Surg 2018; 44:140–143 8. Emanuel E, Tanden N, Altman S, Armstrong S, Berwick D, de Brantes F, Calsyn M, Chernew M, Colmers J, Cutler D, Daschle T, Egerman P, Kocher B, Milstein A, Oshima Lee E, Podesta JD, Reinhardt U, Rosenthal M, Sharfstein J, Shortell S, Stern A, Orszag PR, Spiro T. A systemic approach to containing health care spending. New Engl J Med 2012; 367:949–954 9. Puri S, Kiely AE, Wang J, Woodfield AS, Ramanathan S, Sikder S. Comparing resident cataract surgery outcomes under novice versus experienced attending supervision. Clin Ophthalmol 2015; 15:1675–1681 10. Roberts JL, Ostapchuk M, Miller KH, Ziegler CH. What residents know about health care reform and what we should teach them. J Grad Med Educ 2011; 3:155–161 11. Andreae MC, Dunham K, Freed GL. Inadequate training in billing and coding as perceived by recent pediatric graduates. Clin Pediatr 2009; 48:939–944 12. Adiga K, Buss M, Beasley BW. Perceived, actual, and desired knowledge regarding Medicare billing and reimbursement; a national needs assessment survey of internal medicine residents. J Gen Intern Med 2006; 21:466–470 13. Lusco VC, Martinez SA, Polk HC Jr. Program directors in surgery agree that residents should be formally trained in business and practice management. Am J Surg 2005; 189:11–13 14. Tran J, Cennimo D, Chen S, Altschuler EL. Teaching billing and coding to medical students: a pilot study. Med Educ Online 2013; 18:21455 15. Committee on the Learning Health Care System in America, Institute of Medicine. Best Care at Lower Cost: The Path to Continuously Learning Healthcare in America. Washington, DC, The National Academies Press, 2012 16. Makary MA, Mehta A, Xu T. Improving wisely using physician metrics. Am J Med Qual 2018; 33:103–105 17. Meeker D, Linder JA, Fox CR, Friedberg MW, Persell SD, Goldstein NJ, Knight TK, Hay JW, Doctor JN. Effect of behavioral interventions on inappropriate antibiotic prescribing among primary care practices; a randomized clinical trial. JAMA 2016; 315:562–570 18. Gunaratne K, Cleghorn MC, Jackson TD. The surgeon cost report card; a novel cost-performance feedback tool. JAMA Surg 2016; 151:79–80 19. Wu AM, Wu CM, Tseng VL, Greenberg PB, Giaconi JA, Yu F, Lum F, Coleman AL. Characteristics associated with receiving cataract surgery in the US Medicare and Veterans Health Administration populations. JAMA Ophthalmol 2018; 136:738–745 20. Kauh CY, Blachley TS, Lichter PR, Lee PP, Stein JD. Geographic variation in the rate and timing of cataract surgery among US communities. JAMA Ophthalmol 2016; 134:267–276 21. Schein OD, Cassard SD, Tielsch JM, Gower EW. Cataract surgery among Medicare beneficiaries. Ophthalmic Epidemiol 2012; 19:257–264 22. Javitt JC, Kendix M, Tielsch JM, Steinwachs DM, Schein OD, Kolb MM, Steinberg EP. Geographic variation in utilization of cataract surgery. Med Care 1995; 33:90–105
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23. Erie JC, Hodge DO, Mahr MA. Joint management of cataract surgery by ophthalmologists and optometrists. Ophthalmology 2016; 123:505–513 24. Vela C, Samson E, Zunzunegui MV, Haddad S, Aubin M-J, Freeman EE. Eye care utilization by older adults in low, middle, and high income countries. BMC Ophthalmol 2012; 12:5 25. McGwin G Jr, Khoury R, Cross J, Owsley C. Vision impairment and eye care utilization among Americans 50 and older. Curr Eye Res 2010; 35:451–458 26. Lee DJ, Lam BL, Arora S, Arheart KL, McCollister KE, Zheng DD, Christ SL, Davila EP. Reported eye care utilization and health insurance status among US adults. Arch Ophthalmol 2009; 127:303–310 n Y, Schein OD, Rubin GS, West SK. Eye care utilization by old27. Orr P, Barro er Americans; the SEE project. Ophthalmology 1999; 106:904–909 28. Puent BD, Klein BEK, Klein R, Cruickshanks KJ, Nondahl DM. Factors related to vision care in an older adult cohort. Optom Vis Sci 2005; 82:612–616 29. Wagner LD, Rein DB. Attributes associated with eye care use in the United States: a meta-analysis. Ophthalmology 2013; 120:1497–1501 n JL. Access to vision 30. Baker RS, Bazargan M, Bazargan-Hejazi S, Caldero care in an urban low-income multiethnic population. Ophthalmic Epidemiol 2005; 12:1–12 31. Sloan FA, Brown DS, Carlisle ES, Picone GA, Lee PP. Monitoring visual status: why patients do or do not comply with practice guidelines. Health Serv Res 2004; 39:1429–1448 32. Zhang X, Saaddine JB, Lee PP, Grabowski DC, Kanjilal S, Duenas MR, Narayan KMV. Eye care in the United States; do we deliver to high-risk people who can benefit most from it? Arch Ophthalmol 2007; 125:411–418 33. Sommer A, Tielsch JM, Katz J, Quigley HA, Gottsch JD, Javitt JC, Martone JF, Royall RM, Witt KA, Ezrine S. Racial differences in the causespecific prevalence of blindness in east Baltimore. N Engl J Med 1991; 325:1412–1417 34. Richter GM, Chung J, Azen SP, Varma R. for the Los Angeles Latino Eye Study Group. Prevalence of visually significant cataract and factors associated with unmet need for cataract surgery; Los Angeles Latino Eye Study. Ophthalmology 2009; 116:2327–2335 35. Winter A. Comparing the mix of patients in various outpatient surgery settings. Health Aff 2003; 22 (6):68–75 36. Fountain TR. Ophthalmic malpractice and physician gender: a claims data analysis (an American Ophthalmological Society thesis). Trans Am Ophthalmol Soc 2014; 112:38–49 37. Tsugawa Y, Jena AB, Figueroa JF, Orav E, Blumenthal DM, Jha AK. Comparison of hospital mortality and readmission rates for Medicare patients treated by male vs female physicians. JAMA Intern Med 2017; 177:206– 213 38. French DD, Margo CE, Campbell RR, Greenberg PB. Volume of cataract surgery and surgeon gender: the Florida ambulatory surgery center experience 2005 through 2012. J Med Pract Manage 2016; 31:297–302 39. Stein JD, Lum F, Lee PP, Rich WL III, Coleman AL. Use of health care claims data to study patients with ophthalmologic conditions. Ophthalmology 2014; 121:1134–1141 OTHER CITED MATERIAL A. Research Data Assistance Center. Medicare Data on Provider Practice and Specialty (MD-PPAS). Available at: https://www.resdac.org/cms-data/files/ md-ppas. Accessed July 28, 2019 B. Centers for Medicare & Medicaid Services. Physician Compare National Downloadable File. Available at: https://data.medicare.gov/PhysicianCompare/Physician-Compare-National-Downloadable-File/mj5m-pzi6. Accessed July 28, 2019 C. ASCRS Clinical Survey 2016. In: EyeWorld 2016; September supplement. Fairfax, VA, Global Trends in Ophthalmology and the American Society of Cataract and Refractive Surgery, 2016; Available at: http: //supplements.eyeworld.org/eyeworld-supplements/2016-ascrs-clinicalsurvey-supplement-dl-hr-no-crops. Accessed July 28, 2019 D. Improving Wisely. Advancing high volume care and lowering costs. Available at: https://www.improvingwisely.org/. Accessed July 28, 2019
Disclosures: None of the authors has a financial or proprietary interest in any material or method mentioned.
ARTICLE
Billing of cataract surgery as complex versus routine for Medicare beneficiaries Sidra Zafar, MD, Peiqi Wang, MD, Divya Srikumaran, MD, Oliver D. Schein, MD, MPH, Jennifer E. Thorne, MD, PhD, Martin A. Makary, MD, MPH, Fasika A. Woreta, MD, MPH
Purpose: To estimate ophthalmologist-level variation in cataract surgery billing and evaluate patient and ophthalmologist characteristics associated with complex cataract surgery coding. Setting: Cross-sectional study. Design: Retrospective case series. Methods: Medicare beneficiaries aged 65 years or older who had cataract surgery between January 1, 2016, and December 31, 2017, were included. Billing of cataract surgery as complex versus routine and patient and physician characteristics associated with billing of cataract surgery as complex were evaluated. Results: An estimated 3.5 million cataract procedures were performed on Medicare beneficiaries in 2016 and 2017. Men (odds ratio [OR], 1.79; 95% confidence interval [CI], 1.75-1.82), patients 75 years or older (versus those aged 65 to 74 years: OR, 1.35; 95% CI, 1.33-1.36), and racial minorities (blacks versus whites:
C
ataract surgery is the most commonly performed surgical procedure in the United States,1,2 and at least 80% of cataract surgery in the U.S. is performed on Medicare beneficiaries.1,3 It is estimated that the Medicare program spends more than $3.4 billion annually treating cataracts.4 As the U.S. population of older adults continues to expand, healthcare expenditures on cataract surgery are expected to rise further.5 One variable cost associated with cataract surgery is the upcoding of the operation as complex based on the use of devices or techniques not usually used in routine cataract surgery (eg, iris-expansion device, suture support for intraocular lens, or use of trypan blue). The incidence of cataract operations billed as complex nearly doubled between 2005 and 2009,6 and the rate has increased faster among minorities.7 As cataract surgery rates continue to rise in the U.S. and Medicare spending continues to outpace overall
OR, 1.80; 95% CI, 1.75-1.85) had increased odds of having cataract surgery coded as complex. The mean rate of coding for complex cataract surgery by individual surgeons (n Z 10 075) in the United States was 11.2%, with significant variation. A high-risk clinical diagnosis code was associated with 40.0% of complex cataract surgeries. Adjusted for patient characteristics, ophthalmologists who graduated from medical school within the past 10 years (OR, 1.35; 95% CI, 1.22-1.49) were more likely to code for complex cataract surgery. Higher volume ophthalmologists were less likely to code for complex cataract surgery than low-volume ophthalmologists.
Conclusions: There was marked variation among ophthalmologists in the use of complex cataract surgery. Some variability might represent inaccurate coding and was not entirely based on differences in referral patterns for more complex patients. J Cataract Refract Surg 2019; 45:1547–1554 Q 2019 ASCRS and ESCRS
Supplemental material available at www.jcrsjournal.org.
economic growth,8 a better understanding of the factors associated with complex billing could help inform efforts to improve coding compliance and reduce avoidable healthcare costs. Although previous studies have suggested this trend toward increased use of complex cataract coding, they have relied on a 5% sample of claims.7 Using 100% of Medicare outpatient claims, we designed a study to assess patient-level and ophthalmologist-level characteristics associated with variations in coding for complex cataract surgery in the U.S. MATERIALS AND METHODS Study Design and Population The Institutional Review Board, Johns Hopkins University School of Medicine, approved this retrospective cross-sectional analysis of 100% Medicare fee-for-service carrier claims accessed from the Centers for Medicare & Medicaid Services. All Medicare beneficiaries 65 years or older who had routine or complex cataract
Submitted: April 3, 2019 | Final revision submitted: June 12, 2019 | Accepted: June 13, 2019 From the Department of Ophthalmology (Zafar, Srikumaran, Schein, Thorne, Woreta), Wilmer Eye Institute, the Department of Surgery (Wang, Makary), Johns Hopkins University School of Medicine, the Department of Epidemiology (Thorne), and the Department of Health Policy and Management (Makary), Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA. Corresponding author: Fasika A. Woreta, MD, MPH, 600 N Wolfe St, Johns Hopkins University, Baltimore 21287, MD. Email: [email protected]. Q 2019 ASCRS and ESCRS Published by Elsevier Inc.
0886-3350/$ - see frontmatter https://doi.org/10.1016/j.jcrs.2019.06.008
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surgery (in 1 or both eyes) between January 1, 2016, and December 31, 2017, were identified based on Current Procedural Terminology (CPT) codes 66984 (routine cataract surgery) and 66982 (complex cataract surgery). Cataract surgery is considered complex if the procedure involves one or more of the following: a dye for staining the anterior capsule, use of an iris-expansion device, use of a capsular tension ring, or suture fixation of an intraocular lens. In all beneficiaries with CPT code 66982, high-risk clinical comorbidities that might qualify the surgery as complex were identified using the International Classification of Diseases (ICD), 10th Revision, clinical modification (ICD-10-CM) diagnosis codes (Table S1, available at http://jcrsjournal.org). Patient Characteristics Patient-related information on age, sex, race, and residential ZIP code was obtained from the Medicare Master Beneficiary Summary File. The ZIP code was mapped to a Federal Information Processing Standard (FIPS) code using the sashelp.zipcode file (SAS, Inc.) and to a core-based statistical area (CBSA) code using a National Bureau of Economics FIPS to CBSA crosswalk to determine the region and type of residence. Based on the place of the service code available on each claim, the procedural setting was categorized into outpatient, ambulatory surgery center, and other. Ophthalmologist Characteristics National provider identifier numbers were available on each claim for identification of the ophthalmologist performing cataract surgery. Surgeon characteristics were obtained from Medicare Data on Provider Practice and SpecialtyA and Physician Compare National Downloadable File.B Characteristics of interest included sex, years since graduation from medical school, primary specialty, practice region and location, and the volume of cataract surgery. The surgeon-level rate of complex cataract surgeries was calculated for ophthalmologists who performed more than 10 cataract surgeries during the study period. Based on the U.S. distribution of this surgeon-level metric, a cutoff of the mean plus 2 times the standard deviations (SDs) was defined for identification of surgeon outliers with high use of complex cataract surgeries. Statistical Analysis Patient characteristics are presented by whether they were billed as a routine versus a complex cataract surgery, and ophthalmologist characteristics are presented by their outlier status. Two-sample t tests were used to compare continuous variables and Pearson chisquare tests to compare categorical variables. A multivariable logistic regression model was fitted using generalized estimating equations to evaluate factors associated with the use of complex cataract surgery codes. The outcome event modeled was coding for a complex cataract surgery. The covariates included patient-level characteristics (age, sex, race, region and type [urban versus rural] of residence, procedural setting, and presence of high-risk clinical diagnosis) and ophthalmologistlevel characteristics (sex, years in practice, and mean annual cataract surgery volume). This model was clustered at the ophthalmologist level and accounted for the correlation of eyes within the same patient for bilateral cases as well as the correlation of patients within the same physician. All statistical analyses were performed using SAS Enterprise software (version 7.1, SAS, Inc.). The significance level was set at a P value less than 0.05.
RESULTS Patient Characteristics
Of the 3 500 891 cataract operations on Medicare beneficiaries in 2016 and 2017, 302 155 (8.6%) were coded as complex. The median age of patients having cataract surgery coded as routine or complex was 73.9 years and 76.5 years, respectively. Male patients and black patients Volume 45 Issue 11 November 2019
had a significantly higher proportion of cataract surgeries coded as complex versus routine (both P ! .0001) (Table 1). On multivariate analysis (Table 2), patient characteristics that were independently associated with the use of complex cataract surgery included age older than 75 years compared with age 65 to 74 years and non-white race compared with white. Black patients’ odds of complex cataract surgery were almost twice as high as that of white patients, and North American Native patients’ odds were 1.58-fold higher than that of white patients. Women were less likely to have a complex cataract than men. Cataract surgeries performed in outpatient hospital settings were more likely to be billed as complex than those performed at an ambulatory surgery center. Ophthalmologist Characteristics
During the study period, 10 075 ophthalmologists performed more than 10 cataract surgeries. The median cataract surgery volume was 229 surgeries (range 11 to 7920) over the 2-year study period, with 2500 ophthalmologists (31.0%) performing 226 or more surgeries (Table 3). Figure 1 shows the state-level variation in complex cataract surgery rates. The highest rates were predominantly in the Midwestern and Northeastern states of New York (13.8%), New Jersey (13.0%), Iowa (12.9%), Connecticut (11.7%), and Massachusetts (11.2%). The overall mean surgeon-level rate of coding for complex cataract surgery was 11.2% (median 7.9%; range 0% to 100%). There was marked variation in surgeon-level use of the complex cataract surgery code (Figure 2). Most cataract surgeons (5999 [59.5%]) had a complex rate of 10% or less. A complex cataract cutoff rate greater than 2 SDs above the mean (95th percentile for use of complex cataract codes) (rate Z 35%) identified 459 (4.6%) outlier surgeons. Complex cataract procedures made up 8.3% of an inlier’s total case volume and 60.7% of an outlier’s total case volume. On multivariate analysis (Table 2), ophthalmologists who graduated within the past 10 years were more likely to code cataract surgeries for patients as complex. Although not statistically significant, a similar trend for was also observed for female ophthalmologists compared with male ophthalmologists. Finally, higher-volume ophthalmologists were less likely to code cataract surgery as complex than ophthalmologists in the lowest quartile with respect to their annual cataract surgery volume (Table 2). Clinical Comorbidities
Of the 302 155 cataract surgeries coded as complex, 120 862 (40.0%) had an associated high-risk clinical diagnosis. Pupil-related abnormalities were most common 64 927 (21.5%) followed by floppy-iris syndrome 35 626 (11.8%) and mature cataracts 25 864 (8.6%). As the proportion of cataract surgeries coded as complex increased, the ophthalmologist-level proportion of patients with any high-risk clinical diagnosis also rose. However, a discrepancy was noted at the ophthalmologist level for complex cataract coding and the percentage of patients
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Table 1. Characteristics of patients billed for routine versus complex cataract surgery. Cataract Surgery Characteristic Age (y) Median Min, max Age group, n (%) 65–74 y 75–84 y 85–94 y R95 y Sex, n (%) Male Female Race, n (%) White Black Asian Hispanic North America native Other or unknown Residence, n (%) Urban Rural Region, n (%) Midwest Northeast South West Other† Setting, n (%) ASC Outpatient hospital Otherz High-risk eye condition, n (%) POAG, n (%)
Routine (n Z 3 198 736)
Complex (n Z 302 155)
73.9 65.0, 106.3
76.5 65.0, 109.2
1 822 102 (57.0) 1 167 419 (36.5) 204 728 (6.4) 4 487 (0.1)
128 692 (42.6) 128 082 (42.4) 43 388 (14.4) 1 993 (0.7)
1 224 900 (38.3) 1 973 836 (61.7)
171 942 (56.9) 130 213 (43.1)
2 806 267 (87.7) 184 433 (5.8) 56 099 (1.8) 41 286 (1.3) 15 357 (0.5) 95 294 (3.0)
247 364 (81.9) 29 883 (9.9) 7 652 (2.5) 5 541 (1.8) 1 849 (0.6) 9 866 (3.3)
2 875 709 (89.9) 323 027 (10.1)
273 958 (90.7) 28 197 (9.3)
728 720 (22.8) 515 855 (16.1) 1 276 718 (39.9) 663 342 (20.7) 14 101 (0.4)
70 037 (23.2) 68 373 (22.6) 105 990 (35.1) 56 408 (18.7) 1 347 (0.5)
2 299 205 (71.9) 827 390 (25.9) 72 141 (2.3) 32 522 (1.0) 113 903 (3.6)
195 065 (64.6) 98 011 (32.4) 9 079 (3.0) 120 951 (40.0) 16 247 (5.4)
P Value* !.0001
d
!.0001
!.0001
!.0001
!.0001
!.0001
!.0001 !.0001
ASC Z ambulatory surgery center; POAG Z primary open-angle glaucoma *Continuous variables compared using independent 2-sample tests and categorical variables using chi-square tests † Included Alaska, Puerto Rico, Virgin Islands, Guam, Northern Mariana Islands z Included office, inpatient hospital, and unassigned type of setting
served with any high-risk diagnosis. For example, of ophthalmologists whose complex cataract surgeries accounted for more than 50% of their surgical volume, the median percentage of high-risk patients ranged between 9.3% and 42.2% (Table 4). DISCUSSION Although the surgeon-level rate of coding for complex cataract surgery in the U.S. was 11.2%, the coding rate by surgeon varied widely (range 0% to 100%). Complex cataract surgery rates also varied between states. We found highrisk clinical diagnoses that might warrant complex cataract extraction were present in only 40% of the cataract surgeries coded as complex, with pupil-related abnormalities being the most common diagnosis. Men, racial minorities, and patients treated at outpatient hospitals were more likely to have their cataract procedure billed as complex. Among ophthalmologists, fewer years since medical school
graduation and a low cataract surgery volume were independently associated with an increased use of complex cataract codes. We also queried coding data for cataract surgery at our institute, a tertiary care center that caters to a large population of referred patients, and found the proportion of complex cataract procedures among 36 ophthalmologists to range from 0.0% to 33.9%, with an overall rate of 11.3% in 2018. Thus, considering that some ophthalmologists (2.7% of total population) were coding for complex cataract surgery as much as 91% to 100% of the time, we believe this variability in cataract coding at a national level is unlikely to be explained solely by differences in referral practice patterns for more complex patients. Financial motivation could be a reason for the variation in the use of complex cataract surgery codes. A study by Gong et al.6 that analyzed Medicare data between 2005 and 2009 found that for every 1.0% decrease in Medicare Volume 45 Issue 11 November 2019
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Table 2. Patient and ophthalmologist characteristics associated with use of complex cataract surgery codes. Characteristic
Adjusted OR
95% CI
P Value*
Ref 1.35 2.31 4.64
d 1.33, 1.36 2.26, 2.35 4.31, 4.99
d !.0001 !.0001 !.0001
Ref 0.56
d 0.55, 0.57
d !.0001
Ref 1.80 1.42 1.33 1.58 1.12
d 1.75, 1.85 1.37, 1.48 1.27, 1.38 1.45, 1.73 1.09, 1.15
d !.0001 !.0001 !.0001 !.0001 !.0001
0.99 1.06 Ref 1.02 0.78
0.93, 1.06 1.00, 1.12 d 0.96, 1.08 0.58, 1.05
.75 .07 d .57 .10
Ref 1.01
d 1.00, 1.03
d .13
Ref 1.20 1.28
d 1.16, 1.25 1.16, 1.42
d !.0001 !.0001
5.1, 76.8 d
!.0001 d
Ref 1.03
d 0.95, 1.12
d .48
1.35 0.93 0.93 Ref
1.22, 1.49 0.83, 1.05 0.84, 1.04 d
!.0001 .23 .20 d
Ref 0.88 0.90
d 0.80, 0.97 0.82, 0.99
d .01 .03
Patient Age group 65–74 y 75–84 y 85–94 y R95 y Sex Male Female Race White Black Asian Hispanic North America native Other or unknown Region Midwest Northeast South West Other Residence Urban Rural Procedure setting ASC Outpatient hospital Other High-risk clinical diagnosis Yes No Ophthalmologist Sex Male Female Years since medical school graduation 0–10 11–20 21–30 R31 Mean annual cataract surgery volume 1st quartile: %50 2nd quartile: 51–115 3rd quartile: 116–225
86.6 Ref
CI Z confidence interval; OR Z odds ratio; Ref Z reference *P ! .05
payment for complex cataracts, there was a 1.12% increase in the complex cataract service volume. They observed that the volume for complex cataract services more than doubled during the studied time frame. No similar trends were noted for noncomplex cataract service volume.6 Another potential source of practice variation might be related to surgeon training, with attending surgeons in teaching institutions more likely to use additional resources, such as trypan blue, when teaching residents.9 However, unless clinically indicated, it is not appropriate
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to upcode such cases. Finally, some of the variation likely reflects misunderstanding of the billing regulations. It is important that surgeons understand such regulations to avoid inadvertent billing errors and the potential for fraud. Newly graduating physicians in particular are increasingly cognizant of gaps in their knowledge of proper documentation and coding,10 and studies have found physicians in a variety of disciplines reporting the need for additional formal training in billing and coding.11–13 Including training on billing and coding during medical education
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Table 3. Characteristics of ophthalmologists with complex cataract rate less than 35% versus 35% or greater.* Characteristic Sex, n (%) Male Female Years since medical school graduation Median Min, max Number (%) 0–10 11–20 21–30 R31 Unknown Practice region, n (%) Midwest Northeast South West Otherz Practice location, n (%) Urban Rural Unknown Mean annual cataract surgery volume Median Min, max Number (%) 1st quartile: %50 2nd quartile: 51–115 3rd quartile: 116–225 4th quartile: R226
Complex Cataract Rate <35% (n Z 9616)
Complex Cataract Rate R35% (n Z 459)
7520 (78.2) 2096 (21.8)
321 (69.9) 138 (30.1)
25 0, 62
23 2, 58
1291 (13.4) 2169 (22.6) 2615 (27.2) 3121 (32.5) 420 (4.4)
88 (19.2) 102 (22.2) 92 (20.0) 161 (35.1) 16 (3.5)
2070 (21.5) 2052 (21.3) 3244 (33.7) 2130 (22.2) 120 (1.3)
81 (17.7) 165 (36.0) 129 (28.1) 80 (17.4) 4 (0.9)
9424 (98.0) 177 (1.8) 15 (0.2)
454 (98.9) 3 (0.7) 2 (0.4)
120 6, 3960
42 6, 983
2293 (23.9) 2385 (24.8) 2462 (25.6) 2476 (25.8)
255 (55.6) 126 (27.5) 54 (11.8) 24 (5.2)
P Value† .001
.75
!.0001
.06
!.0001
*Cutoff for identification of high utilizers calculated as mean C 2 SD of national physician distribution, corresponding to R95th percentile † Continuous variables compared using independent 2-sample tests and categorical variables using chi-square tests z Included Alaska, Puerto Rico, Virgin Islands
might increase proficiency in basic coding and billing skill.14 Healthcare-related waste continues to be an endemic problem, comprising up to 30% of all medical spending
and accounting for an estimated $210 billion in excess spending each year.15 In particular, physician-level clinical variation remains a major barrier to quality improvement, and the use of physician-level instead of hospital metrics
Figure 1. State-level rate of complex cataract procedures in 2016 and 2017 in the United States.
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Figure 2. Distribution of ophthalmologistlevel rate of complex cataract procedures in 2016 and 2017 in the United States.
has been proposed to encourage changes in physician behavior.16 Findings in large-scale peer comparison studies reported reductions in inappropriate antibiotic prescribing rates and in operative costs by 5%17 and 7%,18 respectively, when physicians were notified of their practice patterns. Previous studies19–21 have shown that geographic variation in several parameters related to cataract surgery, including in the age of patients at initial cataract surgery, duration from initial cataract diagnosis to first surgery, and state-level cataract surgery rates. The interstate variation in coding for complex cataract surgery rates likely reflects some combination of local distribution of patient and provider characteristics. Possible explanations that have been postulated include variations in a patient’s motivation for surgery, differences in eyecare professional availability, and the assertiveness of ophthalmologists in recommending surgery. Socioeconomic status, the number of optometrists per 100 000 residents, and joint management of cataract surgery by ophthalmologists and
optometrists have also been found to be associated with variations in regional cataract surgery rates.20,22,23 Erie et al.23 found that the lowest joint management rates of cataract surgery were in the Northeast and Southwest regions of the U.S. (regions with higher use of complex cataract surgery codes in our study). The highest rates were in the Southeast and Midwest (regions with lower use of complex cataract surgery codes in our study). However, additional research would be needed to explore the underlying causes for the geographic variation in the use of complex cataract surgery codes that we observed.23 We hypothesize that the patient-level differences we identified for complex cataract coding might have been attributable to underuse of and/or delayed access to appropriate ophthalmic care in these patient populations, leading to more mature cataracts at presentation. Multiple studies from high-income countries, including the U.S., have consistently shown men to have significantly lower rates of eyecare use than women.24–29 In the study by
Table 4. Cataract surgeries coded as complex and proportion of patients with high-risk clinical diagnosis at the level of the ophthalmologist. Ophthalmologist-Level: Patients with Any High-Risk Diagnosis (%) Complex Procedures 0% 1%–10% 11%–20% 21%–30% 31%–40% 41%–50% 51%–60% 61%–70% 71%–80% 81%–90% 91%–99% 100%
Physicians (n)
Mean ± SD
Median
IQR
Min, Max
679 5320 2565 885 324 165 59 29 14 8 16 11
2.7 G 13.2 2.7 G 6.7 7.4 G 10.4 11.2 G 12.4 14.3 G 14.2 19.2 G 20.0 20.8 G 22.9 29.6 G 27.9 32.1 G 33.8 42.5 G 38.8 24.5 G 33.5 38.3 G 44.4
0.0 0.8 5.5 7.6 9.4 10.9 9.3 23.9 18.1 42.2 9.3 20.7
0.0, 0.0 0.0, 3.6 0.2, 11.7 0.3, 19.8 0.6, 26.7 0.5, 37.2 0.0, 48.7 1.5, 46.2 0.0, 70.2 2.5, 80.0 1.3, 24.7 0.0, 90.4
0.0, 100 0.0, 100 0.0, 100 0.0, 100 0.0, 78.6 0.0, 98.9 0.0, 69.4 0.0, 95.0 0.0, 77.2 0.0, 90.5 0.0, 100 0.0, 100
IQR Z interquartile range
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Mahr et al.,7 men were almost twice as likely as women to have a small pupil–related ICD-9-CM diagnosis in association with a complex cataract surgery code, which was attributed to the higher use of a-adrenergic receptor antagonists in men.7 Similarly, studies that have evaluated disparities in eyecare access and use in the U.S.27,30–32 found race to be a significant variable in eyecare uptake across all age groups. In the Baltimore Eye Survey,33 black participants were 5 times more likely than white patients to have an unoperated cataract. In the Los Angeles Latino Eye Study,34 35% of all Hispanic participants who needed cataract surgery had not had the procedure. Last, Winter35 found that Medicare patients treated at ambulatory surgery centers, including those having cataract removal, were on average medically less complex than patients receiving similar procedures in hospital outpatient departments. Hence, we suggest that because of their associated medical comorbidities, these patients might be more likely to have surgery later, leading to more advanced cataracts at presentation. Significant variations can exist among graduating residents not only with respect to their overall surgical volume but also in respect to their surgical exposure to complex cataract cases. We hypothesize that younger surgeons with limited experience might therefore have a lower threshold for the use of trypan blue and/or instruments to facilitate complex cases compared with surgeons who have been in practice for longer; the same might be true for low-volume surgeons. A study by Puri et al.9 that assessed resident cataract surgery performed under supervision of a novice attending surgeon found significantly increased use of trypan blue by the novice surgeon compared with a surgeon with more than 11 years of clinical experience. The authors argued that the greater use of trypan might have reflected the novice surgeon’s desire to facilitate the surgery and might not necessarily have been correlated to the level of cataract. Albeit not statistically significant, we also found a trend toward higher use of complex cataract surgery codes by female surgeons than by their male counterparts. There is evidence from other branches of medicine that men and women might practice medicine differently,36,37 and sexbased differences in annual cataract surgery volumes are known to exist in ophthalmology.38 It would be of interest to explore additional differences that might exist between female and male ophthalmologists in their practice patterns and resource use across a variety of ophthalmic interventions. Moreover, although women compromise almost 30% of the ophthalmologist workforce with 10 years or less of experience, they account for only 18% and 11% of the workforce with more than 10 and 30 years of experience, respectively.C Our findings should be considered in the context of an important limitation. Our study could not account for actual patient clinical findings or referral bias at a granular level. It is likely that some surgeons care for more complex patients and would be expected to code cataract surgeries as complex at rates higher than the national mean. However, we doubt that such differences in patient populations would account
for the range in “coding as complex” that was observed or for the finding of higher rates among lower volume surgeons. Furthermore, our study population was Medicare fee-for-service beneficiaries and might not be generalizable to Medicare Advantage beneficiaries. In addition, because of the limitations of the type of data available in a Medicare claims database, our study was unable to adjust for factors, such as practice setting or subspecialty. Finally, our study was limited to patients 65 years or older, which limits the generalizability of our findings to younger patients. These limitations withstanding, our study was based on 100% capture Medicare carrier claims, which allowed for evaluation of a large, diverse group of individuals receiving care in different settings across the U.S.39 Also, because more than 80% of all cataract surgery is covered by Medicare, trends among Medicare beneficiaries can be considered a barometer of national trends.3 The Improving Wisely collaborativeD uses national data to identify overuse patterns for various diagnostic, medical, and surgical procedures. In the Improving Wisely model, an overuse metric is developed by expert consensus and Medicare data are queried to identify physician outliers and inliers.14 Confidential, benchmarked, personalized audit, and feedback data reports are shared with physicians to change physician behavior and reduce overuse and cost waste. Such an approach is a possible mechanism to address avoidable excess costs associated with inappropriate upcoding. Knowing where one stands in comparison to peers might assist in education and self-regulation. In conclusion, we found substantial variability in the rate at which eye surgeons code for complex cataract surgery. That variability is not likely explainable based on differences in referral practices for more complex patients. Inaccurate use of the code for complex surgery is common and likely reflects some combination of misunderstanding of the intent of the code and financial incentive. Cataract surgeons should take a more proactive approach to address the wide variation in complex cataract surgery rates and help to create consensus physician-level metrics. Such physicianspecific and physician-endorsed metrics can subsequently be presented in peer comparison reports to provide actionable feedback to physicians with outlier practice patterns.
WHAT WAS KNOWN Racial minorities have significantly higher rates of complex cataract surgery than white Medicare beneficiaries.
WHAT THIS PAPER ADDS There was large variation in the use of complex cataract surgery codes among ophthalmologists and between states. An associated high-risk clinical diagnosis was present in fewer than one half of all surgeries coded as complex. Ophthalmologists who graduated within the past 10 years from medical school were more likely to code cataract surgery as complex, whereas higher volume ophthalmologists were less likely to code cataract surgery as complex.
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REFERENCES 1. Erie JC, Baratz KH, Hodge DO, Schleck CD, Burke JP. Incidence of cataract surgery from 1980 through 2004: 25-year population-based study. J Cataract Refract Surg 2007; 33:1273–1277 2. Klein BEK, Howard KP, Lee KE, Klein R. Changing incidence of lens extraction over 20 years; the Beaver Dam Eye Study. Ophthalmology 2014; 121:5–9 3. French DD, Margo CE, Behrens JJ, Greenberg PB. Rates of routine cataract surgery among Medicare beneficiaries [research letter]. JAMA Ophthalmol 2017; 135:163–165 4. Brown GC, Brown MM, Menezes A, Busbee BG, Lieske HB, Lieske PA. Cataract surgery cost utility revisited in 2012; a new economic paradigm. Ophthalmology 2013; 120:2367–2376 5. The Eye Diseases Prevalence Research Group. Prevalence of cataract and pseudophakia/aphakia among adults in the United States. Arch Ophthalmol 2004; 122:487–494 6. Gong D, Jun L, Tsai JC. Trends in Medicare service volume for cataract surgery and the impact of the Medicare physician fee schedule. Health Serv Res 2017; 52:1409–1426 7. Mahr MA, Hodge DO, Erie JC. Racial/ethnic differences in rates of complex cataract surgery among United States Medicare beneficiaries. J Cataract Refract Surg 2018; 44:140–143 8. Emanuel E, Tanden N, Altman S, Armstrong S, Berwick D, de Brantes F, Calsyn M, Chernew M, Colmers J, Cutler D, Daschle T, Egerman P, Kocher B, Milstein A, Oshima Lee E, Podesta JD, Reinhardt U, Rosenthal M, Sharfstein J, Shortell S, Stern A, Orszag PR, Spiro T. A systemic approach to containing health care spending. New Engl J Med 2012; 367:949–954 9. Puri S, Kiely AE, Wang J, Woodfield AS, Ramanathan S, Sikder S. Comparing resident cataract surgery outcomes under novice versus experienced attending supervision. Clin Ophthalmol 2015; 15:1675–1681 10. Roberts JL, Ostapchuk M, Miller KH, Ziegler CH. What residents know about health care reform and what we should teach them. J Grad Med Educ 2011; 3:155–161 11. Andreae MC, Dunham K, Freed GL. Inadequate training in billing and coding as perceived by recent pediatric graduates. Clin Pediatr 2009; 48:939–944 12. Adiga K, Buss M, Beasley BW. Perceived, actual, and desired knowledge regarding Medicare billing and reimbursement; a national needs assessment survey of internal medicine residents. J Gen Intern Med 2006; 21:466–470 13. Lusco VC, Martinez SA, Polk HC Jr. Program directors in surgery agree that residents should be formally trained in business and practice management. Am J Surg 2005; 189:11–13 14. Tran J, Cennimo D, Chen S, Altschuler EL. Teaching billing and coding to medical students: a pilot study. Med Educ Online 2013; 18:21455 15. Committee on the Learning Health Care System in America, Institute of Medicine. Best Care at Lower Cost: The Path to Continuously Learning Healthcare in America. Washington, DC, The National Academies Press, 2012 16. Makary MA, Mehta A, Xu T. Improving wisely using physician metrics. Am J Med Qual 2018; 33:103–105 17. Meeker D, Linder JA, Fox CR, Friedberg MW, Persell SD, Goldstein NJ, Knight TK, Hay JW, Doctor JN. Effect of behavioral interventions on inappropriate antibiotic prescribing among primary care practices; a randomized clinical trial. JAMA 2016; 315:562–570 18. Gunaratne K, Cleghorn MC, Jackson TD. The surgeon cost report card; a novel cost-performance feedback tool. JAMA Surg 2016; 151:79–80 19. Wu AM, Wu CM, Tseng VL, Greenberg PB, Giaconi JA, Yu F, Lum F, Coleman AL. Characteristics associated with receiving cataract surgery in the US Medicare and Veterans Health Administration populations. JAMA Ophthalmol 2018; 136:738–745 20. Kauh CY, Blachley TS, Lichter PR, Lee PP, Stein JD. Geographic variation in the rate and timing of cataract surgery among US communities. JAMA Ophthalmol 2016; 134:267–276 21. Schein OD, Cassard SD, Tielsch JM, Gower EW. Cataract surgery among Medicare beneficiaries. Ophthalmic Epidemiol 2012; 19:257–264 22. Javitt JC, Kendix M, Tielsch JM, Steinwachs DM, Schein OD, Kolb MM, Steinberg EP. Geographic variation in utilization of cataract surgery. Med Care 1995; 33:90–105
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23. Erie JC, Hodge DO, Mahr MA. Joint management of cataract surgery by ophthalmologists and optometrists. Ophthalmology 2016; 123:505–513 24. Vela C, Samson E, Zunzunegui MV, Haddad S, Aubin M-J, Freeman EE. Eye care utilization by older adults in low, middle, and high income countries. BMC Ophthalmol 2012; 12:5 25. McGwin G Jr, Khoury R, Cross J, Owsley C. Vision impairment and eye care utilization among Americans 50 and older. Curr Eye Res 2010; 35:451–458 26. Lee DJ, Lam BL, Arora S, Arheart KL, McCollister KE, Zheng DD, Christ SL, Davila EP. Reported eye care utilization and health insurance status among US adults. Arch Ophthalmol 2009; 127:303–310 n Y, Schein OD, Rubin GS, West SK. Eye care utilization by old27. Orr P, Barro er Americans; the SEE project. Ophthalmology 1999; 106:904–909 28. Puent BD, Klein BEK, Klein R, Cruickshanks KJ, Nondahl DM. Factors related to vision care in an older adult cohort. Optom Vis Sci 2005; 82:612–616 29. Wagner LD, Rein DB. Attributes associated with eye care use in the United States: a meta-analysis. Ophthalmology 2013; 120:1497–1501 n JL. Access to vision 30. Baker RS, Bazargan M, Bazargan-Hejazi S, Caldero care in an urban low-income multiethnic population. Ophthalmic Epidemiol 2005; 12:1–12 31. Sloan FA, Brown DS, Carlisle ES, Picone GA, Lee PP. Monitoring visual status: why patients do or do not comply with practice guidelines. Health Serv Res 2004; 39:1429–1448 32. Zhang X, Saaddine JB, Lee PP, Grabowski DC, Kanjilal S, Duenas MR, Narayan KMV. Eye care in the United States; do we deliver to high-risk people who can benefit most from it? Arch Ophthalmol 2007; 125:411–418 33. Sommer A, Tielsch JM, Katz J, Quigley HA, Gottsch JD, Javitt JC, Martone JF, Royall RM, Witt KA, Ezrine S. Racial differences in the causespecific prevalence of blindness in east Baltimore. N Engl J Med 1991; 325:1412–1417 34. Richter GM, Chung J, Azen SP, Varma R. for the Los Angeles Latino Eye Study Group. Prevalence of visually significant cataract and factors associated with unmet need for cataract surgery; Los Angeles Latino Eye Study. Ophthalmology 2009; 116:2327–2335 35. Winter A. Comparing the mix of patients in various outpatient surgery settings. Health Aff 2003; 22 (6):68–75 36. Fountain TR. Ophthalmic malpractice and physician gender: a claims data analysis (an American Ophthalmological Society thesis). Trans Am Ophthalmol Soc 2014; 112:38–49 37. Tsugawa Y, Jena AB, Figueroa JF, Orav E, Blumenthal DM, Jha AK. Comparison of hospital mortality and readmission rates for Medicare patients treated by male vs female physicians. JAMA Intern Med 2017; 177:206– 213 38. French DD, Margo CE, Campbell RR, Greenberg PB. Volume of cataract surgery and surgeon gender: the Florida ambulatory surgery center experience 2005 through 2012. J Med Pract Manage 2016; 31:297–302 39. Stein JD, Lum F, Lee PP, Rich WL III, Coleman AL. Use of health care claims data to study patients with ophthalmologic conditions. Ophthalmology 2014; 121:1134–1141 OTHER CITED MATERIAL A. Research Data Assistance Center. Medicare Data on Provider Practice and Specialty (MD-PPAS). Available at: https://www.resdac.org/cms-data/files/ md-ppas. Accessed July 28, 2019 B. Centers for Medicare & Medicaid Services. Physician Compare National Downloadable File. Available at: https://data.medicare.gov/PhysicianCompare/Physician-Compare-National-Downloadable-File/mj5m-pzi6. Accessed July 28, 2019 C. ASCRS Clinical Survey 2016. In: EyeWorld 2016; September supplement. Fairfax, VA, Global Trends in Ophthalmology and the American Society of Cataract and Refractive Surgery, 2016; Available at: http: //supplements.eyeworld.org/eyeworld-supplements/2016-ascrs-clinicalsurvey-supplement-dl-hr-no-crops. Accessed July 28, 2019 D. Improving Wisely. Advancing high volume care and lowering costs. Available at: https://www.improvingwisely.org/. Accessed July 28, 2019
Disclosures: None of the authors has a financial or proprietary interest in any material or method mentioned.