Physician Quality Reporting System: PQRS 2011 made easy
April 26, 2011
By Rebecca H. Wartman, O.D., AOA Practice Advancement Committee member
Just when you thought you understood the jargon and knew what you were talking about, the Centers for Medicare & Medicaid Services (CMS) decides to change the terms it uses. The Physician Quality Reporting Initiative (PQRI) is now the Physician Quality Reporting System (PQRS).
Brief overview of PQRI history
First there was “Pay for Reporting,” which was voluntary for 2007 to 2014 (the Tax Relief and Health Care Act of 2006 [TRHCA] authorized the financial incentive for professionals for reporting quality data codes). The Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA) allowed the continued authorization for PQRI in 2009-2010. Then came the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) that expanded the bonus payments through 2010 at a 2 percent bonus level. And finally came the Affordable Care Act (ACA) of 2010 that created a 1.0 percent bonus in 2011 and a 0.5 percent bonus from 2012 to 2014. And for those who do not report, Medicare reimbursement will be reduced by 1.5 percent in 2015 and by 2.0 percent in 2016.
PQRS reporting codes
PQRS measures are reported with what are termed Quality Data Codes (QDC). The QDCs consist of Healthcare Common Procedure Coding System G code set (HCPCS) and Current Procedural Terminology Level II codes (CPT® II), which are performance codes developed by CPT. HCPCS codes are used for measures without published CPT® II codes or for measures required to share CPT® II codes. If a CPT® II code is implemented before being published in the CPT book, the codes are posted online. Note that not all published CPT® II codes are utilized for PQRS.
How to report PQRS
There are several ways to report for PQRS. Optom-etrists will use either paper-based CMS 1500 claims or electronic-based filing.
Other reporting methods are in place, but are not currently appropriate for optometry to use. The other methods of reporting are registry reporting (no clinical registries specific to eye care), measures groups (no measure groups appropriate for optometry) and electronic health records (EHR) reporting (no measures specific to eye care). Registry reporting may replace claims-based reporting in the future, and EHR reporting may replace other reporting methods in the future as well.
At the present time, the AOA is investigating the potential development of a clinical eye care registry, reviewing current registries for reporting some measures by optometry and actively reviewing EHR reporting mechanisms for future use.
All PQRS measures must be reported on the same claim on which CPT® I codes are filed. No registration is required to participate, and it is still strictly voluntary for 2011.
QDCs for each PQRS measure are put in as a line item on a claim just like any procedure code would be entered and are entered with a charge of $0.00 or at a nominal charge, such as $0.01. If a measure exclusion modifier is needed, the modifier would be placed in the same place on the claim form that any other modifier would be placed. All QDCs must file with CPT® I and linked to the appropriate diagnosis. Each of the QDC line items will be denied for payment using N365. This denial code of N365 indicates: This procedure code is not payable. It is for reporting/ information purposes only. As well, this denial code indicates that the measure was sent on to a National Claims History (NCH) file for PQRS analysis. Please keep in mind that providers MAY NOT resubmit only to add a QDC. If a claim is resubmitted only to add the QDC, it will not be included in the analysis or be counted. However, if providers need to resubmit a claim for any other reason, they should be sure to include the appropriate QDCs when sending in the re-filed claim.
PQRS reporting hints
Some hints for successful reporting:
1. Track all claims submitted with PQRS
2. Each QDC line will have an N365 denial code
3. Ensure there is an NPI attached to each line item, including QDC line items
4. Include QDCs on corrected claims (cannot re-file only to add QDC)
5. Use exclusion 8P modifier judiciously
2011 PQRS bonus
The bonus payment for 2011 will be 1 percent of all Medicare-allowable charges, including the technical component (TC) of diagnostic services. The bonus will be paid to the holder of the Tax Identification Number (TIN).
For satisfactory claims-based reporting, providers must report at least three measures 50 percent of time for each measure. This DOES NOT mean that providers must file three measures on every Medicare claim submitted. It means that they must submit measures for at least 50 percent of the claims where the appropriate diagnosis and appropriate evaluation and management codes are filed.
The AOA recommends that ODs submit QDCs for all reportable cases. There is no penalty for more frequent reporting, and frequent reporting will aid in meeting the 50 percent goal.
There are two reporting periods for 2011. Jan. 1, 2011, to Dec. 31, 2011, and July 1, 2011, to Dec. 31, 2011.
The 2011 PQRS bonus will be paid sometime in the third or fourth quarter of 2012. Reports for 2009 were paid in late October and early November 2010. Reports are available by NPI for each TIN. Access reports are available through the PQRI Quality Reporting Portal for the TIN at www.qualitynet.org or from the contractor/carrier by NPI.
PQRS basics
First, this is the terminology used by PQRS:
1. Numerator – Appropriate QDC code(s)
2. Denominator –
a. CPT I codes
b. Any appropriate diagnosis indicated
c. Additional factors such as age and frequency
Second, here is some background on the PQRS in general. There are 194 measures for 2011: five new measures for claims and registry reporting, 11 new registry-only measures, four new measures for EHR-based reporting only (20 EHR measures in total) and 14 measures groups, which includes one new measures group for asthma. There are five measures that were retired and will no longer be used. The retired measures are as follows:
1. 114: Preventive Care and Screening: Inquiry Regarding Tobacco Use
2. 115: Preventive Care and Screening: Advising Smokers and Tobacco Users to Quit
3. 136: Melanoma: Follow-Up Aspects of Care
4. 139: Cataracts: Comprehensive Preoperative Assessment for Cataract Surgery with Intraocular Lens (IOL) Placement
5. 174: Pediatric End-Stage Renal Disease (ESRD): Plan of Care for Inadequate Hemodialysis
2011 PQRS eye care measures
For simplicity, only the PQRS measures directly related to eye care and the Electronic Prescribing Measure (eRx), which is a separate bonus program, will be discussed. The entire PQRS measure list and details can be found at www.cms.gov/PQRI.
When seeing Medicare patients, there are only three diseases to be concerned about in relation to PQRS:
1. Age-related macular degeneration (AMD), dry or wet
2. Glaucoma – primary open-angle only
3. Diabetes – insulin or non-insulin dependent
If providers have any of these diagnoses for a Medicare patient, they should think PQRS. If they report an evaluation and management code OR any ophthalmic office visit code, they should use:
1. 99201-99205; 99212-99215
2. 92004, 92014, 92002, 92012
(While not specifically discussed in this article, the evaluation and management codes allowed include nursing home and rest home codes.)
If using any of these visit codes, think PQRS.
Once providers have determined their claim has one or more of the three diagnosis code and one of the office visit codes, they are only a short step away from properly billing PQRS and earning the 2011 bonus.
For the majority of the 2011 PQRS eye care measures, the actual action described in the measure only has to be performed one time during the reporting period or during a 12-month period. However, the provider needs to report the QDC on each and every claim submitted for a particular patient with the appropriate diagnosis and visit codes.
Age-related macular degeneration
The allowable diagnosis codes are 362.50, 362.51, and 362.52. The patient must be 50 years of age or older. There are two PQRS measures available for use.
- 2019F – Provider looked at the macula through a dilated pupil and noted any macular thickening and/or hemorrhages. And these findings are documented in the patient record (Measure 14)
Chances are excellent that providers are fulfilling the requirements of this measure on each of their AMD patients. If in the rare event that a provider did not or cannot examine the macula through a dilated pupil, there are a few ways to report the measure anyway and indicate that the step was not performed. The provider still gets credit for the PQRS encounter when using a modifier. Simply add a modifier to the measure that indicates why the step was not taken.
- 2019F
– 1P medical reason for not looking at the macula through a dilated pupil
– 2P patient reason for not looking at the macula through a dilated pupil
– 8P no reason for not looking at the macula through a dilated pupil (you just did not) - 4177F Provider discussed the pros and cons of the AREDS formula of supplements with the patient and made proper recommendations on the use of AREDS – this does NOT mean they have to recommend AREDS, just discuss why or why not the AREDS formula is right for a specific patient. And this discussion must be documented in the patient record.
Again, in the event that providers cannot or did not discuss the AREDS recommendations with the patient, they can still file the measure and get credit using the appropriate exclusion modifier.
- 4177F 8P no reason for not discussing AREDS recommendations (just did not)
Glaucoma
The allowable diagnosis codes are 365.01, 365.11, 365.12, and 365.15. The patient must be age 18 or older. There are two PQRS measures available for use.
- 2027F Provider looked at the optic nerve – with or without dilated view of the optic nerve (Measure 12)
If the provider is unable to view the optic nerve in a glaucoma patient, the following exclusion measures should be used when filing the measure.
– 1P Medical reason for not viewing the optic nerve
– 8P No reason for not viewing optic nerve (you just did not)
Controlled IOP
- 3284F Intraocular pressure (IOP) was reduced by at least 15 percent below pre-intervention levels (Measure 141).
If unable to document the patient’s IOP, a provider would file the measure with the following exclusion measure.
– 8P IOP was not documented and no reason given (it just is not)
Uncontrolled IOP
- 0517F and 3285F IOP not reduced by at least 15 percent below pre-intervention levels and a plan of care is in place to get the IOP under control (Measure 141)
If providers are unable to either put a plan of care in place to reduce the IOP or if they did not record the IOP, they would file the measure using the following exceptions.
– 0517F 8P No plan of care documented
– 3285F No exceptions listed (if did not record IOP use 3284F 8P and do not use 0517F or 3285F)
Diabetes
There are two different measures for reporting on a patient with diabetes.
Diabetic with or without retinopathy
The diagnosis codes for this measure are 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 and 648.01-648.04.
The patient must be between the ages of 18 to 75. If they are older than 75 or younger than 18, this measure would not be used. This measure has four different QDCs to choose from; however, two of these codes are for remote imaging so they will not be discussed.
- 2022F Dilated eye exam in a diabetic patient (Measure 117)
If providers did not perform a dilated eye exam on a diabetic patient, they would use:
– 2022F 8P no reason for not performing (you just did not or could not)
Or they could use the following code to report the measure, if indeed the patient had a normal exam within the last year.
– 3072F Low risk of diabetic retinopathy-normal exam in the last year (Measure 117).
No exclusion codes exist for this code.
Diabetic retinopathy
For patients with diabetic retinopathy, providers would report the following measure if the patient is 18 years or older. The diagnoses allowed are 362.01, 362.02, 362.03, 362.04, 362.05, and 362.06.
- 2021F: Documentation of the presence or absence of macular edema (ME) and the level of diabetic retinopathy (DR) (Measure 18)
If providers cannot document the presence or absence of macular edema and the level of diabetic retinopathy for a patient, there are three exclusion codes available for use when reporting.
2021F
– 1P medical reason for not documenting ME/DR
– 2P patient reason for not documenting ME/DR
– 8P no reason for not looking not documenting ME/DR (just did not)
- 5010F and G8397 OR G8398
For patients with DR, this set of codes is used to report communication of diabetic retinopathy and the presence or absence of macular edema to the patient’s primary care physician.
- 5010F – Communicated the presence or absence of macular edema and the level of diabetic retinopathy to the physician responsible for the diabetes care (Measure 19)
If communication does not occur, there are three exclusion codes that can be used to file this measure.
5010F
– 1P medical reason for not communicating
– 2P patient reason for not communicating
– 8P no reason for not communicating
In addition, providers must file one of the two following codes along with 5010F to indicate that a dilated macular or fundus examination was performed.
- G8397 – Dilated macular or fundus exam performed and ME/DR were documented (Measure 19)
OR - G8398 – Dilated macular or fundus exam was not performed (Measure 141)
Neither of these last two codes have exclusion modifiers that can be used with them.
Diabetes Examples
For the diabetic patient, providers may actually have to report up to four different codes.
1. DM without retinopathy, age 18-75: 2022F
2. DM with retinopathy and report, age 18-75: 2022F, 2021F, 5010F, G8397
3. DM without retinopathy, under 18/over 75: no code to report
4. DM with retinopathy and report, under 18/over 75: 2021F, 5010F, G8397
Combined examples
1. AMD + DM (no retinopathy), 52 years old: 2019F, 4177F, 2022F
2. AMD + G (controlled), 35 years old: 2027F, 3284F
3. AMD + G (uncontrolled) + DM 72 years old: 2019F, 4177F, 2027F, 0517F, 3285F, 2022F
4. G (uncontrolled) + DM with DR, 72 years old: 2027F, 0517F, 3285F, 2022F, 2021F, 5010F, G8397
5. AMD + G (controlled) + DM, 78 years old: 2019F, 4177F, 2027F, 3284F
Electronic prescribing
There is a 1 percent incentive payment for using electronic prescribing and reporting at least 25 unique e-prescribing events in the reporting period. The reporting period for 2011 is from Jan. 1, 2011, to Dec. 31, 2011.
If providers receive the 2011 Medicare Electronic Health Record Incentive for 2011, they will not receive the 2011 e-prescribing bonus payment. E-prescribing participation can be done through claims-based reporting, a qualified registry, or a qualified EHR.
The only reporting code for e-prescribing is as follows:
- G8553 At least one prescription created during the encounter was generated and transmitted electronically using a qualified eRx system
For some provider types, there will be a 1 percent reduction penalty in Medicare payments if the provider does not use eRx in 2011. But at this time, optometry is exempted from this penalty.
Why participate in PQRS?
Participating in PQRS for 2011 is important for a number of reasons. Obviously, an extra 1 percent bonus might not add up to a lot of money for many providers. However, in 2011, the CMS is publishing the names of all providers who participated in PQRS with the implication that these providers may provide a higher quality of care.
The New Participating Physician Directory (www.medicare.gov) is listing doctors who attempted PQRI for 2007-2008 and listing who successfully reported for 2009. The statement that is accompanying these reports states:
“This initiative will help your doctor and Medicare provide the highest level of quality of care for people like you, who have Medicare. Medicare greatly appreciates that your doctor has chosen to join this important initiative.”
For the 2011 PQRS, the CMS said it will post the names of providers who:
1. Submit data on the 2011 PQRS quality measures through one of the reporting mechanisms
2. Meet one of the proposed satisfactory reporting criteria for individual measures or measures groups for the 2011 PQRS
3. Qualify to earn a PQRS incentive payment for covered professional services furnished during the applicable 2011 PQRS reporting period
The CMS will eventually publicly report performance information, including the measures collected under PQRS.
Future of PQRS
The CMS hopes to provide options for providers to receive more timely feedback reports, including interim reports.
It is supposed to create an informal review for disputes on whether satisfactory PQRS reporting was done. If it’s within 90 days from the release of report, a provider can appeal a negative report through the Quality Net Help Desk. The providers who appeal would receive a response given in writing within 60 days, and any decisions made would be final without further review or appeal.
The CMS plans to retain the claims-based reporting mechanism, the registry-based reporting mechanism, and the EHR-based reporting mechanism through 2011, but will consider significantly limiting the claims-based mechanism of reporting in future program years.
PQRS incentives through 2014 will be 0.5 percent for 2012-2014 with PQRS payment adjustment (penalties) beginning in 2015 of 1.5 percent and 2.0 percent for 2016 and beyond.
The CMS also has to develop a plan to integrate reporting under the PQRS and reporting under the EHR Incentive Program by Jan. 1, 2012. And finally, the CMS is supposed to develop a more timely feedback process.
Summary
The PQRS for 2011 has not changed very much. Consider using the seven eye care measures detailed above on all claims that have the appropriate diagnosis codes and visit codes.
And remember, providers do not have to use PQRS measures on every claim to be successful. They only need to use the PQRS codes on the claims for patients with glaucoma, macular degeneration and diabetes. It does not have to be hard.
Find more information, including flow sheets for each measure, a summary sheet for use in the office, a power point presentation of this information, and many other tools, at:
Find more information on e-prescribing at:
Happy coding…
