11

22 PQRI/PQRS BILLERS WORKSHOP UNDERSTANDING THOSE FUNNY LOOKING CODES ELAINE SCHMIDT, CPC

3 GOALS 2011 PQRI codes for Optometry Diagnosis; diseases are the key Demonstrate usage-minimize confusion Implementation; not sink or swim Modifiers for PQRI measures Fine tuning Good for your practice 3

4 CARROT STICK VS STICK ANALOGY Carrot stick now for incentive -Positive reinforcement Stick later -Negative result (if positive doesn’t provided initiative) 4

55 PQRI 2011 Physician Quality Reporting Initiative Now PQRS: Initiative replaced with System Quality Data Codes (QDC) Over 200 total measures for Eyecare Measures (2 are for OMDs only) 1 technology code-Electronic medical record (EMR or EHR) Other measures could be used additionally by ODs *Separate E-prescribing measure (G8553) At this time, used for Medicare only (ALL MEDICARE)

66 4 Eye Diseases Primary Open Angle Glaucoma (POAG) Age Related Macular Degeneration (ARMD) Diabetes (DM) Diabetic Retinopathy (DR)

77 Diagnosis When patients files are reviewed and any of the mentioned eye diseases are diagnosed; ask your doctor if any of the PQRI measures could be reported.

88 INCENTIVE FINANCIALLY REWARDED 1 % bonus payment if you qualify (based on all allowable Medicare charges- not just claims with measures) Additional, separate 1% bonus with eRx- NOT included in usage of 3

99 PAY FOR REPORTING Pay for Reporting-not pay for performance (1 st step toward pay for performance) Voluntary at this time Intent is to improve patient care by thinking about what you are doing

10 REQUIREMENTS For satisfactory reporting: Use of at least 3 measures (QDC) for all reportable cases (encounters) This does NOT mean 3 QDC are used on each claim. (Usage - 50% on applicable encounters) NO REGISTRATION IS REQUIRED TO PARTICIPATE

11 Code Placement 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.

12 REPORTING PERIODS Two reporting periods: 01/01/2011 – 12/31/ /01/2011 – 12/31/2011-designed for practitioners getting started (so even if you don’t get started until later, you can still qualify)

13 CPT Category II codes Consist of four numbers and an alpha character They have their own modifiers Used with Category I procedure codes (our “normal” procedure codes) Most are listed in your current CPT Current Procedural Terminology

14 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

15 Participating Physician Directory CMS reversed initial decision on publishing provider names of those who participated Medicare.gov Listing of providers who attempted PQRI CMS decided by listing names, they would be encouraging participation by physicians as patients can view this list

16 MODIFIERS (exclusion modifiers) 1P: excluded due to medical reasons (contra-indicated) 2P: excluded due to patient reasons (patients refused, etc) 3P: *Gone for eyecare measures 8P: not performed (but could have), reason not specified. Still get credit Use carefully, thoughtfully

17 Modifier exception Exception for modifier use: Modifiers are NOT used with the “G” measures

18 RETIRED MEASURES #134007FARMD-ARED prescribed/recommended (this was replaced with a SIMILAR MEASURE) #151055FCataracts: visual functional status assessment #163073FCataracts: pre-surgical measurement #172020FCataracts: pre-surgical dilated fundus evaluation

19 RETIRED MEASURES #114 – 1000F, 1034F, 1035F, 1036F Tobacco Use Assessed #115 – G8455, G8456, 4000F, 4001F Advising Smokers To Quit

20 RETIRED MEASURES #129G8423, G8424, G8425, G8426 Universal influenza vaccine screening and counseling #139 – 0014F Cataracts; Pre-op Assessment for Cataract Surgery G8443, G8445, G8446 E-Prescribing *removed as part of PQRI and in separate incentive

21 # F POAG Optic Nerve Evaluation Dilation is NOT required Age 18+ Allowed Dxs: , , , , CPT 1 codes: , (consults) , (care facility setting)

F 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

23 Example 2027F Service line 1: Service line 2: 2027F365.11

24 # 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: , ,

F AMD Level 1 CPT Procedure codes: , , , Modifiers: 1P 2P (patient refused dilation) 8P

26 Example 2019F AMD Line Line 22019F 2P Measure was not done as patient refused dilation

27 # 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: , , , , ,

28 DM/DR 250.0X – Diabetes with Ophthalmic Manifestation -Principal Dx per ICD X – DR per ICD-9 states “must first code diabetes” (DR is the manifestation)

F DR CPT Level 1 codes: , , , Modifiers: 1P, 2P, 8P

F DR Example Dx (field 21 on HCFA form) x (BDR) (Macular Edema) Svc line x Svc line 22021F Dx 3 is listed because macular edema (ME) was documented, but not used as a pointer

31 # 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 Dxs: , , , , ,

F 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 32

F +(and) G8397 *OR G8398 G8397-Dilated Fundus Exam (DFE) performed, including documentation level of DR and +/- ME (and communicated with managing physician – 5010F) G8398-DFE NOT performed (Would be reported ALONE; without 5010F as 5010F requires DFE)

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

35 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

36 Example 5010F and G F 2P G No communication due to patient reason, but DFE performed 8P can be used, if reason for not communicating is not stated

37 G8398 Use alone (don’t use with 5010F) NO DFE Example: G This shows no DR communication with physician managing diabetes because no DFE was performed

38 # F, 2024F, 2026F, 3072F Dilated Eye Exam-DM Age 18-75* 2022F: DFE with interpretation, documented and reviewed *This will be most frequently used 2024F: 7 standard field stereoscopic photos with interpretation documented and reviewed 2026F: Eye imaging validated to match Dx from 7 standard field stereoscopic photos results documented and reviewed 3072F: Low risk for DR (no DR in previous year) Not likely to be used because patient should have been dilated within the past year

F, 2024F, 2026F, 3072F Allowed Dxs: , , , , , , , , , , 357.2, , , CPT Level 1 codes: , , , , , , , (G0270, G HCPCS Medical nutrition therapy)

F, 2024F, 2026F, 3072F Must be performed at least once in a 12 month period Modifier: 8P only-no dilation performed, not specified (excluding 3072F-not applicable) Reminder: cut off at age 75

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

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

43 # F AMD Counseling on AREDS Counseling on both benefits and risks of antioxidant (AREDS) use documented Age 50+ Allowed Dxs: , , CPT Level 1 codes: , (no 99211), , , ,

F-AMD-AREDS Counseling patient and/or caregiver Counseled at least once in a 12 month period This measure does NOT state recommended or prescribed use Modifiers: 8P: (FYI: if patient is a smoker, AREDs would not be recommended)

45 Example 4177F-AMD-AREDS Line F F Counseling on AREDS and dilated macular exam for AMD If DFE was not performed but could have; append the correct modifier of 1P,2P, or 8P

46 # F, OR 0517F & 3285F POAG, IOP reduction POAG: Reduction of IOP (intraocular pressure) by at least 15% OR documentation of plan of care Age 18+ Documented at least once in a 12 month period Multiple QDC may be required for this measure

F OR 0517F & 3285F POAG & IOP 3284F: IOP reduced by >15% from pre- intervention level OR 0517F: GLC plan of care documented AND 3285F: IOP reduced <15% from pre- intervention level

F, 0517F, 3285F POAG & IOP Allowed Dxs: , , , CPT Level 1 codes: , , , , ,

49 Example 3284F POAG & IOP F 8P IOP not documented, reason not specified

50 Example 0517F, 3285F POAG IOP F 8P (Plan of Care) 3285F IOP reduced < 15% 8P: plan of care NOT documented, reason not specified Plan of care: could include recheck of IOP at specified time, change in therapy, perform additional diagnostic evaluations, monitoring per patient decisions, referral to a specialist

F, 0517F, 3285F POAG & IOP Combinations of QDC required: 3284F:IOP reduced by at least 15% 0517F & 3285F: Care plan documented & IOP reduced <15% 0517F & 3285F 8P: IOP reduced < 15%, no care plan-reason not stated 3284F 8P: IOP reduced at least 15%, no IOP documented, reason not specified

52 # F Pre-op Cataract IOL Placement RETIRED effective Jan. 1, 2011 Surgeons ONLY Cataracts: Comprehensive Preoperative Assessment for Cataract Surgery with IOL Placement ODs do NOT report

53 #124 G8447 or G8448 HIT HIT-Health Information Technology Adopt or use of Electronic Medical Record (EMR) or Electronic Health Record (EHR) G8447: Use of certified EHR G8448: Use of qualified, not certified EMR

54 G8447, G8448 EMR To be qualified, the EMR must be capable of generating: Medication list Problem list Ability to manually enter or electronically receive, store and display laboratory results as discrete searchable data elements Ability to meet basic privacy and security elements

55 G8447 or G8448 EMR Used on all patient encounters (essentially all office visits, but NOT used if ONLY special testing is performed for the date of service) No age specifications No modifiers would be used

56 #130 G8427, G8428 or G8429,G8430 or G8507 Documentation/Verification of Current Medications in the Medical Record Current medications with dosages AND verification documented

57 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 Lots of documentation!

58 G8428 or G8429-Medication Documentation G8428: Provider documentation of current medications with dosages without documented patient verification OR G8429: Incomplete/no provider documentation of current medications, dosages were assessed-no reason stated (most commonly used)

59 G8430 or G8507-Medication Documentation Current medications with dosages not documented, patient not eligible G8430: Provider documentation that patient is not eligible for medication assessment OR Current meds-dosages documented, patient verification not documented, patient not eligible G8507: Provider documentation that patient is not eligible for patient verification of current medications

60 G8427, G8428, G8429, G8430, G8507-Medication Documentation Age 18+ Use with essentially with all office visits No modifiers

61 # F and 1034F or 1035F or 1036F-Tobacco Use Inquiry regarding tobacco use RETIRED effective Jan. 1, 2011

62 # F, 4001F, G8455, G8456, G8457 Advising Smokers to Quit RETIRED effective Jan. 1, 2011

63 #128 G8417, G8418, G8420, G8421, G8422-BMI Universal Weight Screening and Follow-Up Calculated body mass index (BMI) Requires EXTENSIVE documentation Not likely to reasonably be used by ODs

64 #125 E-Prescribing Incentive Program Separate Bonus payments % % % Reduction in payment for not using E-Rx 1% %2013 2%2014 and each following year

65 E-Prescribing G8553 At least one Rx was created, generated & transmitted electronically using a qualified E-Rx system during a patient encounter Calendar year reporting 1/1/2010 – 12/31/20101 Report a minimum of 25 times during the reporting period -Does NOT require reporting 50% of eligible encounters

66 E-Prescribing G8443, G8445, and G8446 deleted FOR 2010, ONLY G8553

67 E-Prescribing-G8553 Age 18+ Reported on every encounter IF E-Rx generated CPT level 1 codes: , , , 90862, , , , , G0101, G0108, G0109

68 E-Prescribing Qualified e-Rx must do ALL of the following: Generate complete active medication list Select medication, print prescriptions, electronically transmit prescriptions, and conduct all alerts Provide information related to lower cost, therapeutically appropriate alternatives (if any) Provide information on formulary or tiered formulary medications, patient eligibility, and authorization requirements received electronically from the patient’s drug plan

69 E-Prescribing For additional information/details:

70 E-Prescribing There are some free products available BCBS: Allscripts

PQRS Highlights 9 Eye care specific measures (2 for only surgeons) 4 eye diseases: POAG, ARMD, DM, DR 1 HIT (Health information technology) (other measures available for use by ODs) E-Rx: separate measure with separate 1% bonus

72 3 measures, 50% of applicable cases 2011 bonus =1% on all allowable Medicare charges (as long as OV submitted) Bonus paid to group tax ID, but results are individual by provider No registration required, not to late to start As always, use proper documentation will have current informationwww.aoa.org

73 Help and guidance is available SO; HAPPY REPORTING!