Transcript BILLERS WORKSHOP

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PQRI/PQRS
BILLERS WORKSHOP
UNDERSTANDING THOSE
FUNNY LOOKING CODES
ELAINE SCHMIDT, CPC
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GOALS
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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
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CARROT STICK VS STICK
ANALOGY
• Carrot stick now for incentive
-Positive reinforcement
Stick later
-Negative result (if positive doesn’t
provided initiative)
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PQRI 2011
• Physician Quality Reporting Initiative
• Now PQRS: Initiative replaced with System
• Quality Data Codes (QDC)
Over 200 total measures for 2019
9 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)
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4 Eye Diseases
Primary Open Angle Glaucoma
(POAG)
Age Related Macular Degeneration
(ARMD)
Diabetes
(DM)
Diabetic Retinopathy
(DR)
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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.
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INCENTIVE
FINANCIALLY REWARDED
1 % bonus payment if you qualify
(based on all allowable Medicare chargesnot just claims with measures)
Additional, separate 1% bonus with eRxNOT included in usage of 3
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PAY FOR REPORTING
Pay for Reporting-not pay for performance
(1st step toward pay for performance)
Voluntary at this time
Intent is to improve patient care by thinking
about what you are doing
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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
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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.
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REPORTING PERIODS
• Two reporting periods:
01/01/2011 – 12/31/2011
07/01/2011 – 12/31/2011-designed for
practitioners getting started
(so even if you don’t get started until later,
you can still qualify)
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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
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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
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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
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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
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Modifier exception
Exception for modifier use:
Modifiers are NOT used with the “G”
measures
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RETIRED MEASURES
#13 4007F
ARMD-ARED
prescribed/recommended (this was
replaced with a SIMILAR MEASURE)
#15 1055F
Cataracts: visual functional
status assessment
#16 3073F
Cataracts: pre-surgical
measurement
#17 2020F
Cataracts: pre-surgical
dilated fundus evaluation
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RETIRED MEASURES
#114 – 1000F, 1034F, 1035F, 1036F
Tobacco Use Assessed
#115 – G8455, G8456, 4000F, 4001F
Advising Smokers To Quit
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RETIRED MEASURES
#129
G8423, 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
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#12 2027F POAG
Optic Nerve Evaluation
Dilation is NOT required
Age 18+
Allowed Dxs:
365.10, 365.11, 365.12, 365.12, 365.15
CPT 1 codes: 92002-92014, 99201-99215
99241-99245(consults)
99307-99310, 99324-99337 (care facility setting)
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2027F
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
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Example 2027F
Service line 1: 99213
365.11
Service line 2: 2027F
365.11
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#14 2019F 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: 362.50, 362.51, 362.52
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2019F AMD
Level 1 CPT Procedure codes:
92002-92014, 99201-99215
99241-99245,
99307-99310, 99324-99337
Modifiers:
1P
2P (patient refused dilation)
8P
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Example 2019F AMD
Line 1
99214
362.50
Line 2
2019F 2P
362.50
Measure was not done as patient refused
dilation
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#18 2021F Diabetic Retinopathy
Document level of DR AND +/- macular
edema-362.07* (MUST CODE DR 1st)
Age 18+
Performed at least once in a 12 month
period
Allowed Dxs: 362.01, 362.02, 362.03,
362.04, 362.05, 362.06
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DM/DR
• 250.0X – Diabetes with Ophthalmic
Manifestation
-Principal Dx per ICD-9
362.0X – DR per ICD-9 states “must first
code diabetes”
(DR is the manifestation)
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2021F DR
CPT Level 1 codes:
92002-92014
99201-99215, 99241-99245,
99307-99310, 99324-99337
Modifiers:
1P, 2P, 8P
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2021F DR Example
Dx (field 21 on HCFA form)
1. 250.5x
2. 362.01 (BDR)
3. 362.07 (Macular Edema)
Svc line 1
92014
250.5x
Svc line 2
2021F
362.01
Dx 3 is listed because macular edema (ME) was
documented, but not used as a pointer
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#19 5010F AND G8397 or G8398Diabetic Communication
-DR communication with physician
managing DM (diabetes) care
Age 18+
Communication is documented at least once
in a 12 month period
Allowed Dxs:
362.01, 362.02, 362.03, 362.04, 362.05,
362.06
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5010F DR COMMUNICATION
• 5010F states findings of DFE are
communicated with physician managing
DM (DFE must be performed)
• 5010F + G8397 says: 1st, DFE (part of
5010F) was performed and documented –
then DR and ME (macular edema) was
communicated to managing physician
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5010F +(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)
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5010F and G8397 or G8398
CPT level 1 codes:
92002-92014,
99201-99215, 99241-99245
99307-99310, 99324-99337
Modifiers:
2P: patient did not want communication
8P: not communicated, not stated why
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Example 5010F and G8397
Svc line 1
99214
362.02 (PDR)
Svc line 2
5010F
362.02
Svc line 3
G8397
362.02
Communicated with physician and DFE performed
Svc line 1
99214
362.02
Svc line 2
5010F 2P
362.02
Svc line 3
G8397
362.02
No communication due to patient reason, BUT
DFE was performed
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Example 5010F and G8397
99214
362.02
5010F 2P
362.02
G8397
362.02
No communication due to patient reason,
but DFE performed
8P can be used, if reason for not
communicating is not stated
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G8398
Use alone (don’t use with 5010F) NO DFE
Example:
92012
362.02
G8398
362.02
This shows no DR communication with
physician managing diabetes because no
DFE was performed
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#117 2022F, 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
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2022F, 2024F, 2026F, 3072F
Allowed Dxs:
250.00-250.03, 250.10-250.13,
250.20-250.23, 250.30-250.33,
250.40-250.43, 250.50-250.53,
250.60- 250.63, 250.70-250.73,
250.80-250.83, 250.90-250.93, 357.2,
362.01-362.07, 366.41, 648.00-648.04
CPT Level 1 codes:
92002-92014, 99201-99215, 99304-99310, 99324-99328,
99334-99337, 99341-99345,99347-99350, (G0270,
G0271 - HCPCS Medical nutrition therapy)
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2022F, 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
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Example 2022F
Field 21 on hcfa:
1 250.50 (dm with ophthalmic manifestation)
2 362.01 (background diabetic retinopathy)
Line 1
99204
250.50
2
2022F
250.50
3
5010F
362.01
4
G8397 362.01
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Example 5010F, G8397, 2022F
Line 1
92004
362.01
2
5010F
362.01
3
G8397
362.01
4
2022F
*250.50 or 362.01
*for example, DM with ophthalmic
manifestation or background DR-either dx
could be used (BDR is a manifestation of
DM)
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#140 4177F AMD
Counseling on AREDS
Counseling on both benefits and risks of
antioxidant (AREDS) use documented
Age 50+
Allowed Dxs:
362.50, 362.51, 362.52
CPT Level 1 codes:
92002-92014, 99201-99215(no 99211),
99241-99245, 99307-99310, 9932499328, 99334-99337
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4177F-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)
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Example 4177F-AMD-AREDS
Line 1 99214
362.51
2 4177F
362.51
3 2019F
362.51
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
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#141 3284F, 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
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3284F OR 0517F & 3285F
POAG & IOP
3284F: IOP reduced by >15% from preintervention level
OR
0517F: GLC plan of care documented
AND
3285F: IOP reduced <15% from preintervention level
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3284F, 0517F, 3285F
POAG & IOP
Allowed Dxs:
365.10, 365.11, 365.12, 365.15
CPT Level 1 codes:
92002-92014, 99201-99205, 99212-99215,
99307-99310, 99324-99328, 99334-99337
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Example 3284F
POAG & IOP
92004
365.11
3284F 8P
365.11
IOP not documented, reason not specified
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Example 0517F, 3285F
POAG IOP
92004
365.11
0517F 8P
365.11 (Plan of Care)
3285F
365.11
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
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3284F, 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
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#139 0014F
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
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#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
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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
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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
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#130 G8427, G8428 or
G8429,G8430 or G8507
Documentation/Verification of Current
Medications in the Medical Record
Current medications with dosages AND
verification documented
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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!
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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)
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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
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G8427, G8428, G8429, G8430,
G8507-Medication Documentation
Age 18+
Use with essentially with all office visits
No modifiers
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#114 1000F and 1034F or 1035F
or 1036F-Tobacco Use
Inquiry regarding tobacco use
RETIRED effective Jan. 1, 2011
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#115 4000F, 4001F, G8455,
G8456, G8457
Advising Smokers to Quit
RETIRED effective Jan. 1, 2011
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#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
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#125 E-Prescribing Incentive
Program
Separate Bonus payments
2009-2010
2%
20111%
2012-2014
.5%
Reduction in payment for not using E-Rx
1%
2012
1.5%
2013
2%
2014 and each following year
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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
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E-Prescribing
G8443, G8445, and G8446 deleted 2010
-FOR 2010, ONLY G8553
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E-Prescribing-G8553
Age 18+
Reported on every encounter IF E-Rx
generated
CPT level 1 codes:
92002-92014, 99201-99215, 90801- 90809,
90862, 96150-96152, 99304-99316,
99324-99337, 99341-99350, G0101,
G0108, G0109
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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
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E-Prescribing
For additional information/details:
www.ehealthinitiative.org.eRx/
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E-Prescribing
There are some free products available
BCBS: Allscripts
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2011 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
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• 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
• www.aoa.org will have current information72
Help and guidance is available
SO;
HAPPY REPORTING!
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