Transcript BILLERS WORKSHOP

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UNDERSTANDING THOSE STRANGE-LOOKING
CODES
ELAINE SCHMIDT, CPC, CPO-C, OCS
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DISCLAIMER
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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
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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
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PQRS-Physician Quality Reporting System
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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
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QDCs-Quality Data Codes
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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
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2014 PQRS Highlights
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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
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NQS-National Quality Strategy
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NQS Domains are new for 2014
-Patient Safety
-Person and Caregiver-Centered Experience &
Outcomes
-Communication and Care Coordination
-Effective Clinical Care*
-Community/Population Health
-Efficiency and Cost Reduction
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NQS Rationale
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Better Care
Healthy People/Healthy Communities
Affordable Care
Due to the ACA (Affordable Care Act) and
implementation of EHRs (Electronic Health
Records)
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WHY?
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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)
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CARROT STICK ANALOGY
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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
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Possible 2015 Penalty Avoidance
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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
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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)
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*2 additional non-eye care specific measures will be needed
*Separate E-prescribing measure (G8553), separate from PQRS
is RETIRED effective 2014. Use of G8553 will result in claim
DENIAL
At this time, used for Medicare only (ALL MEDICARE)
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Register?
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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
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The Eye Care Measures
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#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 + 0517F
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Measures/Domains
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All except measure #141-POAG/IOP are in
the Effective Clinical Care Domain
#141 is in the Communication/Care
Coordination Domain
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“Additional Measures”
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2 additional measures + 1 additional domain to
report successfully are needed
7 measures to *select from
*3 allow 92000 & 99000 CPT 1 codes
*4 require CPT 1 99000 use only; 92000s are NOT
allowed
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Additional Measures allowing 92000 CPT I
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#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, G8952
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Additional Measures-allowing only 99000
CPT I
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#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)
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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))
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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)
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CONSIDERATIONS
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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)
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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.
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Applicable Measures
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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
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Measures
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#140-AMD:AREDS - 4177F – Counseling on
risks/benefits on antioxidant supplement
#141-POAG:IOP – 3284F or 3285F + 0517F –
Reduction of IOP > or < 15% and plan of care
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Others
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#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
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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
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PENALTY
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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
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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
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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.
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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
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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
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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
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Numerator/Denominator
Terminology
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Numerator is simply the appropriate QDC code(s)
-CPT II codes
-HCPCS G codes
Denominator effects the Numerator use – so are:
-92000 General Ophthalmologic codes or 99000
Evaluation & Management CPT I codes
-Appropriate Diagnosis
-Factors such as age and frequency
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MODIFIERS
(exclusion modifiers)
1P: excluded due to medical reasons (contraindicated)
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
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Good News & Considerations
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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
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#12 2027F POAG
Optic Nerve Evaluation
Dilation is NOT required
Age 18+
Allowed Dxs:
365.10, 365.11, 365.12, 365.15
CPT 1 codes: 92002-92014, 99201-99215
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*99211 is NOT used with ANY PQRS measures
*E&M care facility codes are usually allowed for
PQRS use
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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
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POAG Example 2027F
Service line 1: 99213
365.11
Service line 2: 2027F
365.11
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#141 POAG, IOP REDUCTION
3284F, or 3285F + 0517F
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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
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3284F POAG IOP
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3284F: IOP reduced by at least 15% from
pre-intervention level
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3285F & 0517F POAG IOP
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*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)
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Examples POAG & IOP
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1. 92004
365.11
3284F 8P (IOP not documented, reason not
specified)
2. 92004
365.11
3285F
365.11(IOP reduced <15%)
0510F 8P
365.11(Plan of Care) not
documented, reason not specified
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0517F Plan of Care
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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
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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
CPT I: 92002-92014, 99201-99215
1P, 2P, 8P
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Example 2019F AMD
Service Line 1
99214
362.50
Service Line 2 2019F 2P
362.50
2 P indicating measure was not done as
patient refused dilation and 2019F descriptor
states dilated macular exam
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#140 4177F AMD AREDS Counseling
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4177F documents counseling on both benefits and
risks of antioxidant (AREDS) use – Not necessarily
the recommendation of their use
Age 50 +
Allowed Dx’s: 362.50. 362.51. 362.52
CPT I codes: 92002-92014, 99201-99215 (no
99211)
Counseling patient and/or caregiver in at least last
12 month period
8P
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Example AMD 2019F, 4177F
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99214
362.51
2019F
362.51
4177F
362.51
-Patient with non-exudative AMD had dilated
macular exam and was counseled on AREDS
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# 117 Diabetes 2022F, 3072F
Dilated Fundus Exam (DFE)
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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
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DM 2022F, 3072F
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Allowed Dx’s:
250.00-250.03, 250.10-250.13,
250.51-250.53, 250.60-250.63,
250.70-250.73, 250.80-250.83
250.90-250.93, 357.2, 362.01-362.07,
366.41, 648.01-648.04
Performed at least once in 12 month period
8P (excluding 3072F-not applicable)
Patient Age 18-75*
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2022F Diabetic Examples
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Example: Patient, age 78 with DM, and NO
retinopathy
NO PQRS codes would be submitted even
though patient’s Dx is 250.00
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
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#18 2021F Diabetic Retinopathy
Document level of DR AND +/- macular edema362.07* (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
*362.07-macular edema would be additionally
documented, if present
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# 18 2021F DR
CPT Level 1 codes:
92002-92014, 99201-99215
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
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#19 5010F + G8397 or G8398 DM with
DR Communication
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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: 362.01, 362.02, 362.03, 362.04,
362.05, 362.06
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5010F Communication + G8397 or G8398alone
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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
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DM/DR Examples
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Claim Dx’s (field 21)
1. 250.5X
2. 362.01(BDR)
3. 362.07 (macular edema)
92014
250.5x
2021F
362.01
5010F
362.01 (Comm. DFE)
G8397
362.01 (DFE performed)
Dx 3 (ME) is listed because present &
documented, but not used as a pointer
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#19 5010F 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)
362.01, 362.02, 362.03, 362.04, 362.05, 362.06
1P, 2P, 8P
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5010F DR COMMUNICATION
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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
CPT level 1 codes:
92002-92014,
99201-99215,
Modifiers:
1P: medical reason
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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G8398
Use alone (don’t use with 5010F) NO DFE
performed
Example:
92012
362.02
G8398
362.02
This shows no DR communication with physician
managing diabetes because no DFE was
performed
*Reminder: Must 1st code DM, then DR which is the
manifestation
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Example 2022F
Field 21 on hcfa:
1 250.50 (dm with ophthalmic manifestation)
2 362.01 (background diabetic retinopathy)
Service 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 250.50
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 for the measure (BDR is a
manifestation of DM)
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#130 G8427, or G8430, or G8428
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
Route documented
Use if best effort made to obtain and document
Lots of verified documentation!
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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)
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G8427, G8428, G8430
Medication Documentation
Age 18+
Use with essentially with all office visits
Can use regardless of diagnosis
No modifiers
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#226 Tobacco Use Screening
4004F or 1036F
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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
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#317 Screening for High Blood
Pressure & Follow-up
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6 measures - select only one
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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
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Screening HBP & Follow-up
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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
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HBP Screening-not eligible
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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
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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
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BE POSITIVE
Help and guidance is available
SO;
HAPPY REPORTING!
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