PQRS for DUMMIES 2011

PQRS means “Physician Quality Reporting System”. Basic PQRS has specifically identified over two dozen “Eligible Professionals” who may participate including Medicare Physicians, Practitioners and Therapists. Medicare has created 194 Quality measures. Of these, 8 different “Quality Measures” could be adopted by Optometrist’s in order to qualify for the 1% incentive bonus in 2011. Previously, they have only counted full years as the measured time period. Starting July 1, 2011, they will count 6 month periods of time. The rules are you must report that you have done at least 3 of these Quality Measures, at least 50% of the time in 2011, (was 80% prior), on Medicare covered patients during the study time period. It applies only to Medicare covered patients and nobody else. The 1% bonus incentive is calculated on your total allowable Medicare payments for CPT procedures performed by the Optometrist (not optical) for the time period being measured, and paid in the following year as a single bonus check in the third or fourth quarter. Previously, it was a 2% bonus incentive authorized by the 2006 Tax Relief and Health Care Act and later modified in 2007 and 2008. This current level of payment specifies 1% for 2011, a .5% bonus from 2012-2014.

For now, you should plan on a reduction (called an “adjustment”) for those who do not report of -1.5% in 2015 and -2% in 2016. It is possible, the adjustments may not apply to Optometrists. Time will tell. If you have the HITECK Certified EMR by then, you will automatically participate and report.

Reporting is done on your HCFA 1500 form or on your electronic claim, by using the appropriate Category II procedure code, with or without applicable modifiers, and a line item charge value of $0.00. Each of the quality health measures is applicable only to a specific group of CPT procedure codes that you routinely use. On the claim form or electronic entry, it is critical the Cat II code appears immediately after, and therefore points to, the applicable CPT procedure code you have billed immediately preceding. You do not have to sign up, or register, or enroll in the program. Just start using the Cat II codes properly.

Why is Medicare offering to pay you a bonus you might ask? What are they after? Is anybody actually doing this? Record reviews and studies have shown that Medicine, and for the ophthalmic quality measures, Ophthalmology, have not documented the provision of quality care regularly, thereby suggesting room for improvement in the delivery of health care to the Medicare population. The payer (Medicare) wants some documentation that providers are using best clinical practice guidelines and evidenced based medicine at least 50% of the time on a few selected diagnoses for the year 2011. They will give you a little bonus incentive to tell them what a great job you are doing, and give you a small penalty adjustment if you are not reporting in the future. They hope to standardize and improve the overall quality of health care provided to their enrollees. To report or not report does not threaten your right to participate in Medicare. If you are not reporting, it does not mean you are not using best clinical practice guidelines or evidenced based medicine. If you are doing a good job caring for your patients using current evidenced base medicine techniques, all you have to do is let Medicare know you are doing a good job to get the bonus, or avoid the penalty if it should still be there for Optometrists in 2015. Successful participants in the 2009 PQRS year are published, and only 5% of licensed optometrists participated. A list with the name and state of eligible professionals who satisfactorily reported Physician Quality Reporting System measures for the 2009 program year is available to the public. The list is alphabetized by first name only, and only the state is listed. No reference is made to medical specialty. Those eligible professionals who are listed, successfully participated by reporting at least 3 quality measures at least 80% of the time in 2009. It is pass/fail. There is no ranking. For 2009, there are over 300,000 names.

On the other hand, if you need a reminder of what is considered “best clinical practice guidelines” for the CPT procedure codes used and the patient’s diagnosis, the Quality Measures referred to will remind you what is expected. You simply need to do what is expected, report it on the claim form, and get paid a bonus over and above the actual billings and allowed amount.

Following are the 8 Quality Measures pertinent to Optometry out of 194 in total for 2011.

In 2011 the PQRS bonus is contingent on achieving 50% success for patients that have a disease/diagnosis that a quality measure you select is being reported for, and achieving that success rate (50%), for at least three quality measures.

Measure 12, Primary Open Angle Glaucoma: Optic Nerve Evaluation

Measure 14, Age Related Macular Degeneration: Dilated Macular Examination

Measure 18, Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level of Severity of Retinopathy

Measure 19, Diabetic Retinopathy: Communication with the Physician Managing On-going Diabetes Care

Measure 117, Dilated Eye Exam in Diabetic Patient

Measure 124, Health Information Technology – Adoption/Use of Health Information Technology (EHR)

Measure 140, Age-Related Macular Degeneration: Counseling on Antioxidant Supplement

Measure 141, Primary Open Angle Glaucoma: Reduction of Intraocular Pressure (IOP) by 15% or Documentation of a Plan of Care.

This is a long list, and somewhat daunting. To comply with basic PQRS for Dummies like me, just pick three and focus yourself and most importantly your staff to constantly monitor the affected diagnoses for the three measures in order to enter the PQRS Cat II codes prior to submitting the claim. Here is the KISS approach. Pick these three Quality Measures to get started. You can add more later.

  1. Primary Open Angle Glaucoma: Optic Nerve Evaluation
  2. Age Related Macular Degeneration: Dilated Macular Exam
  3. Dilated Eye Exam in Diabetic Patient

You do all of these already. Now you just have to tell Medicare you did it, or if not, why not, for every single time you see the patient with this diagnosis code. It is that simple. For these three, the applicable CPT procedure codes that would qualify for the PQRS Quality Measure Cat II codes are all of the Evaluation and Management Codes for office or out-patient visits, new or established, and the two CPT “General Ophthalmological Services”, Comprehensive or Intermediate, new or established. (Remember to list the Cat II code immediately after the E&M Code or the Eye Code on the claim) In other words, you do not add PQRS incentive Cat II codes to “Special Ophthalmological Services”, “Ophthalmoscopy”, or “Other Specialized Services” listed under Ophthalmology in the CPT book. Submission of the Cat II PQRS code must be done on the initial claim; it cannot be re-submitted after the fact. However, if it was submitted on the initial claim, and a corrected claim has to be resubmitted later, do include the Cat II codes as well. Check your computer billing system. It may already have PQRS Compliance Reports to review before billing Medicare to make this really easy.

2011 PQRS

FOLLOWING ARE THREE SUGGESTED MEDICARE QUALITY MEASURES FOR THE PQRS BEGINNER

 

PRIMARY OPEN ANGLE GLAUCOMA

            PATIENT AGE: 18+

            DX CODE: 365.10, 365.11, 365.12, 365.15

            PROCEDURE CODE: 99201-99205, 99212-99215, 92002-92014

           USE CAT II:   2027F if patient had dilated optic nerve evaluation performed in the last 12 months

                        (doesn’t have to be at this visit)

                        2027F 1P        if not performed in the last 12 months for medical reasons

                        2027F 8P        if not performed in the last 12 months for unspecified reason

                                                (The 1P of 8P are listed as modifiers on the claim form)

AGE RELATED MACULAR DEGERATION, wet or dry – DILATED MACULAR EXAM

            PATIENT AGE: 50+

            DX CODE: 362.50, 362.51, 362.52

            PROCEDURE CODE: 99201-99205, 99212-99215, 92002-92014

USE CAT II:   2019F if patient had a dilated exam in past 12 months WITH

                        DOCUMENTED PRESENCE OR ABSENCE OF MACULAR THICKENING OR

                        HEMORRHAGE AND LEVEL OF SEVERITY (does not have to be this visit)

     OR USE:   2019F  1P        if not performed for medical reason

                        2019F  2P        if not performed because declined by patient

                        2019F  8P        if not performed for other reasons

DILATED RETINAL EXAM ON DIABETIC PATIENT

            PATIENT AGE: 18 – 75

            DX CODE: 250.00-250.93, 362.01-362.07

            PROCEDURE CODE: 99201-99205, 99212-99215, 92002-92014

USE CAT II:   2022F              if dilated retinal exam for diabetes performed this visit

     OR USE:   2022F  8P        if dilated exam not performed for other reason

For the most part, you will use 2027F, 2019F or 2022F as the Cat II PQRS code with a dollar value of $0.00. Program your computer billing system with the Cat II procedure name (i.e. Glaucoma PQRS) with the CPT code of 2027F and a charge of $0.00 and have your staff enter it immediately behind the office visit code and away you go with no effort on your part (assuming you have done a dilated optic nerve evaluation in the previous 12 months for the current visit being billed).

If you have questions, or need advice please contact me at This email address is being protected from spambots. You need JavaScript enabled to view it. . Good luck!

Don Sipola OD, FAAO

AOS Volunteer State Liaison-MN

AOS Founding Member

413 Chestnut St., Virginia, MN   55792

www.optometricsociety.org

(An Eligible Professional Who Satisfactorily Reported Physician Quality Reporting Measures for 2009)