1 1

UNDERSTANDING THOSE STRANGE-LOOKING CODES ELAINE SCHMIDT, CPC, CPO-C, OCS 2 2

DISCLAIMER This information is current as to the time it was prepared. Reasonable effort was made to assure accuracy. There is no guarantee of being completely error-free. This presentation is intended to be a tool to assist and guide understanding.

GOALS 2014 PQRS codes for Optometry Diagnosis; diseases are the key Demonstrate usage and minimize confusion Implementation; not sink or swim Modifiers for PQRS measures Fine tuning Good for your practice 4 4

PQRS-Physician Quality Reporting System PQRS is a method of reporting to Medicare that specific *tasks have been performed and documented regarding certain diagnoses and Medicare patients The way those tasks are reported is attaching Quality Data Codes (QDC)when billing Medicare PQRS and QDC are essentially interchangeable 5

QDCs-Quality Data Codes QDCs are actual CPT II procedure codes QDCs are reported on Medicare claims the same way as other procedure codes Each QDC must be linked to the appropriate diagnosis code The are “billed” at 0 $ or.01 depending on what your software The “regular” procedure codes billed are CPT I 6

2014 PQRS Highlights Must report 9 measures using 3 domains with a successful 50% threshold to receive 2014 bonus Individual provider NPI must be correctly used to identify performing physician Reports are by NPI for each TIN-obtained by contractor/carrier or via IACS ICD-10 code information will become available as the October 1, 2014 implementation date approaches 7

NQS-National Quality Strategy NQS Domains are new for Patient Safety -Person and Caregiver-Centered Experience & Outcomes -Communication and Care Coordination -Effective Clinical Care* -Community/Population Health -Efficiency and Cost Reduction 8

NQS Rationale Better Care Healthy People/Healthy Communities Affordable Care Due to the ACA (Affordable Care Act) and implementation of EHRs (Electronic Health Records) 9

WHY? Aside from being *required (*to avoid penalty), there are benefits PQRS is a measure of quality care which makes them: Good for patients Good for your practice Insurers and patient advocacy groups are tracking usage -And very important: ODs need to recognized as being Primary Care Providers (PCPs) 10

CARROT STICK ANALOGY Carrot stick (bonus) was the incentive.5% bonus for 2013 and 2014 for those who qualify =Positive Reinforcement Painful stick looking forward: Those providers that did NOT report beginning in *2013 will be seeing a reduction of 1.5% in 2015, 2% in 2016 and each year after 11

Possible 2015 Penalty Avoidance IF you have ANY unfiled 2013 Medicare claims that qualify having a PQRS measure attached AND those claims; (even just 1 claim) are filed prior to February 28, 2014 – the 2015 penalty could be avoided. That penalty is 1.5% on all qualifying Medicare charges 12

PQRS 2014 Physician Quality Reporting System Previously known as PQRI: “Initiative” replaced with “System” Quality Data Codes (QDC)-interchangeable with PQRS 11 Eyecare Measures 7 that ODs need to be concerned with relating to disease (4 others for OMDs, specifically cataract surgeons and the cataract measure group excludes modifier use- 54/55) *2 additional non-eye care specific measures will be needed *Separate E-prescribing measure (G8553), separate from PQRS is RETIRED effective Use of G8553 will result in claim DENIAL At this time, used for Medicare only (ALL MEDICARE) 13

Register? There is no registration or sign up needed to participate in PQRS Just start using, aka, reporting the measures *Voluntary for 2014; BUT if not used, will be penalized in 2016 – so voluntary with consequences if you choose not to participate 14

The Eye Care Measures #12 POAG – (ON evaluation) CPT II 2027F #14 AMD (dilated macular exam) – CPT II 2019F #18 DR – CPT II 2021F #19 DR – CPT II 5010F, G8397 or G8398 #117 DM – CPT II 2022F or *(2024F, 2026F, 3072F) #140 AMD (AREDS) – CPT II 4177F #141 POAG (IOP) – CPT II 3284F, 3285F F 15

Measures/Domains All except measure #141-POAG/IOP are in the Effective Clinical Care Domain #141 is in the Communication/Care Coordination Domain 16

“Additional Measures” 2 additional measures + 1 additional domain to report successfully are needed 7 measures to *select from *3 allow & CPT 1 codes *4 require CPT use only; 92000s are NOT allowed 17

Additional Measures allowing CPT I #130-Documentation of Current Medications in the MR – HCPCS G8427, G8430, G8428 (Patient safety) #226-Tobacco screening – HCPCS 4004F, 1036F (Community/population health) #317-HBP screening – HCPCS G8783, G8950, G8784, G8951, G8785, G

Additional Measures-allowing only CPT I #110-Influenza screening (Community/population health) #111-Pneumonia Vaccination Status (Effective Clinical care) #128-BMI (Community/population health) #173-Screening Unhealthy Alcohol Use (Community/population health) 19

3 Diseases to consider Primary Open Angle Glaucoma (POAG) Age Related Macular Degeneration (ARMD) Diabetes Insulin and Non-insulin Dependent (DM, including Diabetic Retinopathy (DR)) 20

New to Reporting? When submitting either a 99xxx, (E&M), or 92xxx, general ophthalmology procedure code claim for a Medicare patient and they have any of the following diseases; think PQRS and what might apply. -Primary Open Angle Glaucoma (POAG) -Age Related Macular Degeneration (ARMD) -Diabetes (DM), including Diabetic Retinopathy (DR) 21

CONSIDERATIONS Don’t worry about using PQRS clinical measures on claims that don’t have a Dx of AMD, GLC, DM, or DR Do not use on claims with testing ONLY If you use an incorrect Dx on a QDC, it DOES count against you You can get the incentive bonus for MU and PQRS You can NOT get the incentive bonus for MU and E-Prescribing(G8553 is RETIRED) 22

Diagnosis When patient records are reviewed and any of the mentioned eye diseases are diagnosed; ask your doctor if any of the PQRS measures could be reported. When claims are received, the diagnosis is considered and evaluated to see if any PQRS measures would be applicable. 23

Applicable Measures MEASURE #s, CPTII and DESCRIPTIONS #12-POAG – 2027F – Optic Nerve Evaluation #14-AMD – 2019F – Dilated Macular Examination #18-DR – 5010F + G8397 or G8398 – Findings of DR patient communicated with physician responsible for managing ongoing diabetes care #117-DM- 2022F –Dilated eye exam in a diabetic patient 24

Measures #140-AMD:AREDS F – Counseling on risks/benefits on antioxidant supplement #141-POAG:IOP – 3284F or 3285F F – Reduction of IOP > or < 15% and plan of care 25

Others #130-Medication documentation – G8427 or *G8430, or G8428 #226 – 4004F or 1036F – Screened for tobacco use; cessation counseling or non-user *#317 – Screened for High Blood Pressure and Follow-up documented *-Need to understand the nuances/criteria of the 6 different HCPCS codes to be able to select the proper HBP code 26

INCENTIVE FINANCIALLY REWARDED.5 % bonus payment if you qualify (based on all allowable Medicare charges-not just claims with measures) Includes *TC of diagnostic services Bonus is paid to the holder of the TIN -Tax Identification Number 27

PENALTY You must have reported in *2013 to avoid penalty in 2015 (possible exception) Minus 1.5% payment adjustment for 2015 if not using in *2013 Minus 2% payment adjustment for 2016 and beyond if not using 28

REQUIREMENTS For satisfactory reporting: Use of at least 9 measures (QDC-quality data codes) from 3 different domains on APPLICABLE (encounters) 50% of the time This does NOT mean 9 QDCs are used on each claim. (Usage - 50% on applicable encounters) NO REGISTRATION IS REQUIRED TO PARTICIPATE 29

Code Placement The PQRS codes are treated as procedure codes on a claim - they are CPTII or HCPCS codes Need to make sure the correct pointer (Dx) is used on the line of service -Correct diagnosis (pointer) is attached to the procedure code/measure. 30

PQRS = CPT Category II codes and HCPCS “G” codes Consist of four numbers and an alpha character CPT II have their own modifiers HCPCS G codes do not use modifiers Used with Category I CPT procedure codes (our “normal” procedure codes) Most are listed in your current CPT Current Procedural Terminology 31

EOB/RA The QDC will be denied on the Medicare remittance advice/notice (RA) as N365- “This procedure code is not payable. It is for reporting/information purposes only” Sent on to National Claims History File (NCH) for analysis 32

Participating Physician Directory CMS reversed it’s initial decision on publishing provider names of those who participated Medicare.gov Listing of providers who attempted PQRS CMS decided by listing names, they would be encouraging participation by physicians due to the fact patients have access to, and can view this list 33

Numerator/Denominator Terminology Numerator is simply the appropriate QDC code(s) -CPT II codes -HCPCS G codes Denominator effects the Numerator use – so are: General Ophthalmologic codes or Evaluation & Management CPT I codes -Appropriate Diagnosis -Factors such as age and frequency 34

MODIFIERS (exclusion modifiers) 1P: excluded due to medical reasons (contra- indicated) 2P: excluded due to patient reasons (patients refused, etc) 8P: not performed (but could have), reason not specified. Still get credit Important to use carefully, thoughtfully *Exception: Modifiers are NOT used with the “G” measures 35

Good News & Considerations If an exception modifier is used (appropriately), the measure use still counts The eye care measures are virtually unchanged for 2014 As a general rule for successful reporting: It is VERY important to use PQRS every time there is a diagnosis & encounter code or it will count against you -Also include 2-3 of the “additional” measures Over-reporting does NOT count against you 36

# F POAG Optic Nerve Evaluation Dilation is NOT required Age 18+ Allowed Dxs: , , , CPT 1 codes: , _______________________________________ *99211 is NOT used with ANY PQRS measures *E&M care facility codes are usually allowed for PQRS use 37

2027F-POAG-ON Evaluation Must be performed at least once in a 12 month period. (Remember, can be used each time applicable, even on the same patient with different date of service) Modifiers: 1P: medical reason, for example, patient had a total cataract-couldn’t see the nerve 8P: not done 38

POAG Example 2027F Service line 1: Service line 2: 2027F

#141 POAG, IOP REDUCTION 3284F, or 3285F F POAG: Reduction of IOP (intraocular pressure) by at least 15% of pre-intervention level or less than 15% reduction with plan of care in place Age 18 + Documented at least once in a 12 month period Same diagnoses, CPT I, and exception modifier 40

3284F POAG IOP 3284F: IOP reduced by at least 15% from pre-intervention level 41

3285F & 0517F POAG IOP *3285F: IOP reduced <15% from pre-intervention level -AND 0517F: GLC plan of care documented (*3285F has no exceptions; if the IOP was not measured USE 3284F) 42

Examples POAG & IOP F 8P (IOP not documented, reason not specified) F365.11(IOP reduced <15%) 0510F 8P365.11(Plan of Care) not documented, reason not specified 43

0517F Plan of Care Plan of care could include: Recheck of IOP at a specified time Change in therapy Perform addition diagnostic evaluations Monitoring per patient decisions Referral to a specialist Unable to achieve due to health system reason 44

# F AMD Age Related Macular Degeneration Dilated Macular Exam Age 50+ Document +/- macular thickening, +/- hemes, AND level of AMD Report at least once in a 12 month period Allowed Dxs: , , CPT I: , P, 2P, 8P 45

Example 2019F AMD Service Line Service Line F 2P P indicating measure was not done as patient refused dilation and 2019F descriptor states dilated macular exam 46

# F AMD AREDS Counseling 4177F documents counseling on both benefits and risks of antioxidant (AREDS) use – Not necessarily the recommendation of their use Age 50 + Allowed Dx’s: CPT I codes: , (no 99211) Counseling patient and/or caregiver in at least last 12 month period 8P 47

Example AMD 2019F, 4177F F F Patient with non-exudative AMD had dilated macular exam and was counseled on AREDS 48

# 117 Diabetes 2022F, 3072F Dilated Fundus Exam (DFE) 2022F: DFE with interpretation, documented and reviewed 3072F: Low risk for DR (no DR in previous exam) *Not likely to be used because the DM patient should have been dilated within the last year (2024F and 3072F-images) Few ODs would use only images, and dilation is the recommended clinical care guideline 49

DM 2022F, 3072F Allowed Dx’s: , , , , , , 357.2, , , Performed at least once in 12 month period 8P (excluding 3072F-not applicable) Patient Age 18-75* 50

2022F Diabetic Examples Example: Patient, age 78 with DM, and NO retinopathy NO PQRS codes would be submitted even though patient’s Dx is If the patient is past age 75, 2022F, 3072F are not applicable (or any of the measures in #117) Patient, age 70 refused dilation 2022F 2P 51

# F Diabetic Retinopathy Document level of DR AND +/- macular edema * (MUST CODE DR 1 st ) Age 18+ Performed at least once in a 12 month period Allowed Dxs: , , , , , * macular edema would be additionally documented, if present 52

# F DR CPT Level 1 codes: , Modifiers: 1P, 2P, 8P Per ICD-9 DR 362.0x is the manifestation of DM 250.5x, so the DM with ophthalmic manifestation (250.5x) must be coded first ICD-10 will address this issue 53

# F + G8397 or G8398 DM with DR Communication Communicated with physician responsible for diabetic care the presence or absence of macular edema and the level of diabetic retinopathy Communication documented at least once in a 12 month period Age 18+ Allowed Dx’s: , , , , ,

5010F Communication + G8397 or G8398- alone 5010F states findings are communicated with DM managing physician G8397: DFE was performed & documented -must be used with 5010F for measure to be complete OR G8398: DFE was NOT performed -G8398 is reported alone; NOT used with 5010F 55

DM/DR Examples Claim Dx’s (field 21) X (BDR) (macular edema) x 2021F F (Comm. DFE) G (DFE performed) Dx 3 (ME) is listed because present & documented, but not used as a pointer 56

# F AND G8397 or G8398-Diabetic Communication -DR communication with physician managing DM (diabetes) care Age 18+ Communication is documented at least once in a 12 month period Allowed Dx’s: (all are DR codes, not DM only) , , , , , P, 2P, 8P 57

5010F DR COMMUNICATION 5010F states findings of DFE are communicated with physician managing DM (DFE must be performed) 5010F + G8397 says: 1 st, DFE (part of 5010F) was performed and documented – then DR and ME (macular edema) was communicated to managing physician 58

5010F and G8397 or G8398 CPT level 1 codes: , , Modifiers: 1P: medical reason 2P: patient did not want communication 8P: not communicated, not stated why 59

Example 5010F and G8397 Svc line (PDR) Svc line 25010F Svc line 3G Communicated with physician and DFE performed Svc line Svc line 25010F 2P Svc line 3G No communication due to patient reason, BUT DFE was performed 60

G8398 Use alone (don’t use with 5010F) NO DFE performed Example: G This shows no DR communication with physician managing diabetes because no DFE was performed *Reminder: Must 1 st code DM, then DR which is the manifestation 61

Example 2022F Field 21 on hcfa: (dm with ophthalmic manifestation) (background diabetic retinopathy) Service Line F F G

Example 5010F, G8397, 2022F Line F G F* or *for example, DM with ophthalmic manifestation or background DR -either Dx could be used for the measure (BDR is a manifestation of DM) 63

#130 G8427, or G8430, or G8428 Documentation/Verification of Current Medications in the Medical Record Current medications with dosages AND verification documented 64

G8427-Medication Documentation List current medications, including dosages and verification with patient or authorized representative – documented Includes Rx, over-the-counter (OTC), herbals, vitamin/mineral/dietary (nutritional) supplements Route documented Use if best effort made to obtain and document Lots of verified documentation! 65

G8428 or G8429-Medication Documentation G8428: Current medications with name, dosages, frequency, route NOT documented, Reason NOT Specified OR G8430: Current medications with dosages NOT documented, Patient NOT eligible (patient not eligible for medication assessment-Patient is in an urgent or emergent medical situation and time is of the essence) 66

G8427, G8428, G8430 Medication Documentation Age 18+ Use with essentially with all office visits Can use regardless of diagnosis No modifiers 67

#226 Tobacco Use Screening 4004F or 1036F Preventative Care and Screening: Tobacco Use: Screening and Cessation Intervention Screened once in 24 month period Age 18+ All diagnosis codes 4004F: Screened as Tobacco user AND received cessation counseling -brief-3 minutes or less, and/or pharmacotherapy OR 1036F: Screened as current non-tobacco user 68

#317 Screening for High Blood Pressure & Follow-up 6 measures - select only one G8733: Normal BP documented, follow-up not required G8950: Pre-Hypertensive for Hypertensive BP reading documented AND the indicated follow-up is documented G8784: BP reading not documented, documentation the patient is not eligible 69

Screening HBP & Follow-up G8951: Pre-Hypertensive or Hypertensive BP reading documented, indicated follow-up not documented, documentation the patient is not eligible G8785: BP reading not documented, reason not given G8952: Pre-Hypertension or Hypertensive BP documented, indicated follow-up not documented, reason not given 70

HBP Screening-not eligible 3 reasons: -Patient has an active diagnosis of hypertension -Patient refused to participate (either BP measurement of follow-up) -Patient is in an urgent or emergent situation where time is of the essence 71

BP Table The AOA is making available a BP table including classification with systolic and diastolic readings along with recommended follow-up Available on the AOA web site 72

BE POSITIVE Help and guidance is available SO; HAPPY REPORTING! 73