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Making Sense of PQRS

Making it SimplePhysician Quality Reporting System2012

Presented byRebecca H. Wartman, O.D.Practice Advancement Committee Member,Clinical and Practice Advancement GroupAmerican Optometric Association

Disclaimers

1. This presentation is current at the time it was published onto the web.

2. Medicare policy changes frequently so links to the source documents have been provided for your reference.

3. This presentation is prepared as a tool to assist providers and is not intended to grant rights or impose obligations.

4. Every reasonable effort has been made to assure the accuracy of the information.

5. Ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services.

6. The American Optometric Association, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this guide.

Disclaimers

6. This presentation is general summary that explains certain aspects of the Medicare program, but is not a legal document. The official Medicare program provisions are contained in the relevant laws, regulations, and rulings.

7. The Medicare Learning Network (MLN) is the brand name for official CMS educational products and information for Medicare fee-for-service providers. For additional information visit the Medicare Learning Network’s web page at www.cms.hhs.gov/MLNGenInfo on the CMS website.

8. Current Procedural Terminology (CPT) is copyright by the American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.

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2012 PQRS

PQRI is out and PQRS is in

• 2010 PQRI– Physician Quality Reporting Initiative = PQRI

• 2011 PQRS “Modern Term”– Physician Quality Reporting System= PQRS

Physician Quality Reporting System 2012PQRS

History Overview

• Pay for Reporting – Voluntary for 2007-2014

• Tax Relief and Health Care Act of 2006 (TRHCA)

– Authorizes financial incentive for professionals reporting quality data

• Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA)

– Continued authorization for PQRI in 2009-2010

• Medicare Improvements for Patients and Providers Act of 2008 (MIPPA)

– Expanded bonus payments through 2010 - 2% bonus

• The Affordable Care Act (ACA) of 2010

– Created a 1.0% bonus in 2011 and a 0.5% bonus in 2012-2014. For those who do not report, reduces Medicare payments by 1.5% in 2015 and by 2.0% in 2016 and every year thereafterSqs

PQRS Form and Manner of Reporting

• Claims based

• Registry reporting- no clinical registries specific to optometry– Registry reporting may replace claims-based reporting in future

• Measures groups –no groups appropriate for optometry

• Electronic Health Records Reporting– EHR reporting available

• AOA is: – investigating potential development of clinical eye care registry

– reviewing current registries for reporting some measures by optometry

• CMS Reporting method decision tree https://www.cms.gov/PQRS/Downloads/2012_PhysQualRptg_DecisionTree11-11-2011.pdf

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PQRS Claims Reporting

– Paper-based CMS 1500 claims

– Electronic based using ASC X 12N Health Care Claim Transaction (Version 5010).

– Must be reported on the same claim as CPT I• Sample CMS 1500 form will be reviewed later tonight

– No registration is required to participate

– Still strictly voluntary for 2012

Satisfactory PQRS ReportingClaims-Based

For satisfactory reporting:Must report at least 3 measures, 50% of time for each measure

This does NOT mean 3 measures on every claim at least 50% of the time.

Choose three measures (or more) and use them when appropriate at least 50% of the time

AOA recommendation: Submit QDC for all reportable cases Frequent reporting will aid in meeting the 50% goal No penalty for more frequent reporting

Reporting Quality Data

• Quality Data Code (QDC) charged at $0.00

(or nominal, such as $0.01)

• Must file with CPT I and other requirements

• PQRS line items denied for payment

• N365: This procedure code is not payable. It is for reporting/information purposes only.

• BUT, sent to National Claims History (NCH) file for PQRS analysis

• MAY NOT resubmit only to add QDC - will not be included in the analysis or counted

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PQRS Reporting Hints

• Track all claims submitted with PQRS

• Each QDC line will have N365 denial code

• Ensure NPI attached to each line item including QDC line items

• Include QDC codes on corrected claims (Cannot re-file only to add QDC)

• Use 8P modifier judiciously

(will discuss later in presentation)

PQRS Bonus Payment

• 0.5% bonus payment for 2012

• Bonus paid on all Medicare allowable 2012 charges

• Includes -TC of diagnostic services

• Bonus paid to holder of TIN

(Tax Identification Number)

Reporting period: January 1,2012- December 31, 2012

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Understanding PQRS Analysis

• For claims bases reporting analysis is by individual NPI under each TIN

– Must have and correctly use individual NPIs

– Requires individual providers identified

– Separate analysis for each TIN

• Must reach the 3 measure-50% threshold

PQRI (S) Feedback Reports

• 2007 PQRI quality reports June 2008• 2008 PQRI quality reports in October 2009• 2009 PQRI quality reports in November 2010• 2010 PQRS quality reports in September 2011• Reports by NPI for each TIN• Access reports via IACS or Contractor/Carrier by NPI

• If report available will be listed at:www.qualitynet.org

2010 PQRIHow did we do?

• Ophthalmology 5,119,625 codes submitted

87.42% correct

• Optometry 1,381,276 codes submitted

81.15% correct

Most errors were incorrect diagnosis

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PQRI 2010Summary of Reporting

2010 Reporting was 3+ measures/80%

• #12: POAG-ONH 80.04% correct

• #141: POAG-Control 81.15% correct

• #14: AMD-DFE 96.05% correct

• #140: AMD-AREDS 96.25% correct

• #18: DM-DR+ME 81.8% correct

• #19: DM-communicate 56.94% correct

• #117: DM-DFE 63.57% correct

2011: very similar so far BUT threshold is 50% so expect more OD earning bonus

2011 PQRSSo far

• Ophthalmology 3,233,738 submitted

87.97% correct

• Optometry 855,532 submitted

85.17% correct

Again most errors are incorrect diagnosis codes

PQRS Participation Considerations

• Physician Compare Website (Medicare.gov)• Listing who successfully reported for 2010

“This professional chose to take part in Medicare's Physician Quality Reporting System and reported quality measure information satisfactorily for the year 2010.”

• Eventually will report performance information, including the measures collected under PQRS

“A physician or other healthcare professional can choose whether to report quality information to Medicare under the Physician Quality Reporting System. Medicare believes that reporting quality information by professionals is an important means to improve the quality of care provided to Medicare beneficiaries.”

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2012 PQRS Measures

• Claims/ Group Reporting: 143 measures• Registry Reporting: 208 measures

– 65 registry only measureshttps://www.cms.gov/PQRS/Downloads/2011_Qualified_Registries_Posting_11-30-2011.pdf

• EHR Reporting: 51 measuresContact your EHR vendor for information

• Measure Group Reporting: 22 groupsNo measure groups appropriate for optometry

• Retired Measures for 2012: 9 measuresNo retired measure impact optometry

2012 PQRS

9 eye care measures were retained for 2011 + 2 new measures• Measure 12 –Primary Open Angle Glaucoma (POAG): Optic Nerve Evaluation• Measure 14 – Age-Related Macular Degeneration (AMD): Dilated Macular Examination• Measure 18 – Diabetic Retinopathy: Documentation of Presence or Absence of

Macular Edema and Level of Severity of Retinopathy• Measure 19 – Diabetic Retinopathy: Communication with the Physician Managing

Ongoing Diabetes Care• Measure 117 – Diabetes mellitus: Dilated Eye Exam in Diabetic Patient • Measure 140 – Age-Related Macular Degeneration (AMD): Counseling on Antioxidant

Supplement• Measure 141 – Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular

Pressure (IOP) by 15% OR Documentation of a Plan of Care

Optometry only needs to be concerned about 7 PQRS measuresNew measures are registry only by patient survey

Cataracts codes are for surgeons (191,192) –registry onlyCataract outcomes by patient reported (303,304)- registry only

2012 PQRS

• 0.5% bonus (total allowed charges for Medicare Part B provided for reporting period)

• Extra 0.5% incentive payment when ABO provides data on Maintenance of Certification Program beyond MOC required by ABOAmerican Board of Optometry one of five fully approved boards accepted by CMSContact ABO for more information

• Claims based reporting threshold reduced– Successful reporting: 3 measure 50% of time– 1 Reporting period for claims based reporting

• 1/1/11-12/31/12• Measure group, registry and EHR reporting rules are different

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PQRS 2012

• Claims must reach National Claims History file by February 22, 2013 to be included in the analysis

• File end of year claims in timely manner

• Cannot refile only to add QDC

• If need to refile any claim, refile the QDC codes as well

PQRS 2012

• Only talk about Eye Care Specific Codes

• Some other codes available if desired BUT WHY

• Information on other codes and methods of reporting available at:

http://www.cms.gov

PQRS Reporting

• Reported with Quality Data Codes (QDCs)

– CPT II codes

• Performance codes developed by CPT

• If implemented before published in CPT book –

posted on line

• Not all published CPT II codes utilized for PQRS

– HCPCS G codes used when:

• measures without published CPT II codes

• measures required to share CPT II codes

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PQRS Basics

• Numerator – Appropriate QDC Code (s)

• CPT II codes

• HCPCS G codes

• Denominator– CPT I codes (E&M; General Ophthalmic codes)

– Any appropriate diagnosis indicated

– Additional factors such as age and frequency

Exceptions Modifiers

What if measure cannot be completed?

• You must still report to be counted or it will count against you

• Use modifiers

– 1P: medical reason

– 2P: patient reason

– 8P: other reason

Physician Quality Reporting SystemPQRS 2012

• Only Three Diagnoses To Think About:–Age Related Macular Degeneration

–Primary Open Angle Glaucoma

–Diabetes: Insulin and Non-insulin Dependent

• ANY OF THESE … THINK PQRS

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Physician Quality Reporting SystemPQRS

• If you report an evaluation & management code

– 99201-99205 or 99212-99215

OR

• If you report a general ophthalmic service code

– 92004,92014, 92002, 92012

• ANY OF THESE CODES - THINK PQRSNo other procedure codes are considered

Nursing Home/Rest Home and other E&M codes eligible as well but will not discuss tonight

Physician Quality Reporting SystemPQRS

If you have the diagnosis and examination code:

The only step left is to add the PQRS code

Must add the PQRS code to every Medicare claim where the diagnosis and examination code is appropriate for the measure

If you do this, you should earn your bonus!

Physician Quality Reporting SystemPQRS

• Rule of thumb:

USE PQRS EVERY TIME YOU HAVE DIAGNOSIS AND ENCOUNTER CODE (with modifiers if needed) OR WILL COUNT AGAINST YOU!

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Physician Quality Reporting SystemPQRS

• Let’s break it down by disease

Age Related Macular Degeneration

• Any of these three diagnoses

– 362.50 Macular Degeneration, NOS

– 362.51 Macular Degeneration, non-exudative

– 362.52 Macular Degeneration, exudative

• Patient age 50 and older

ARMD

• Two PQRS measures to use (#14,#140):

2019F and 4177F

• 2019F:– Dilated view of macula

– Recorded +/- macular thickening and

+/- hemorrhages

You must dilate and record finding, once per 12 month period - once per reporting period

BUT YOU MUST REPORT EVERY TIME USE ARMD DIAGNOSIS CODES

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ARMD Exceptions

• 2019F– 1P medical reason for no dilated macula view

– 2P patient reason for no dilated macula view

– 8P other reason for no dilated macula view

ARMD

4177F:

– Discussed pros and cons of AREDS

– Made proper recommendations for individual

– Documented discussion

You must discuss and record your recommendation, once per 12 month period - once per reporting period for each unique patient … BUT YOU MUST REPORT EVERY TIME you see the patient

ARMD Exceptions

• 4177F

– 8P no reason for not discussing AREDS

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Glaucoma –Primary Open Angle

Two PQRS measures to be used (12,141):2027F 3284F or 0517F+3285F

Will discuss these two measures together• Any of these four diagnoses

– 365.10 Open angle glaucoma, unspecified– 365.11 Primary open angle glaucoma– 365.12 Low Tension Glaucoma– 365.15 Residual Open Angle Glaucoma– 365.70-365.74 (new codes used in conjunction with regular

glaucoma diagnoses)

• Patient age 18 years and older

Glaucoma

• Two different reporting options

– Controlled IOP

• 2027F and 3284F

– Uncontrolled IOP

• 2027F and 0517F & 3285F

Glaucoma Controlled

• 2027F - Viewed optic nerve(With or without dilation)

• 3284F - IOP reduced 15% or more from pre-intervention levels

Once in a 12 month period -per reporting period

Report every time you use diagnosis and exam code

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Glaucoma Controlled Exceptions

2027F

• 1P medical reason for not viewing optic nerve

• 8P no reason for not viewing optic nerve

3284F

• 8P IOP not documented, no reason given

Glaucoma Uncontrolled

• 2027F- Viewed optic nerve

• 3285F- IOP NOT reduced 15% from pre-intervention levels

&

• 0517F- Plan of care to get IOP reduced

Once in a 12 month period or reporting period

Report every time you use diagnosis and exam code

Glaucoma Uncontrolled

• 0517F Plan of care examplesrecheck of IOP at specified time

change in therapy

perform additional diagnostic evaluations

monitoring per patient decisions

unable to achieve due to health system reasons

referral to a specialist

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Glaucoma Uncontrolled Exceptions

2027F

• 1P medical reason for not viewing optic nerve

• 8P no reason for not viewing optic nerve

3285F

• No exceptions – use 3284F 8P if did not measure IOP

0517F

• 8P no plan of care to reduce IOP documented

Diabetes

Three different PQRS measures (18,19,117):2022F or 3072F; 2021F; 5010F+G8397 or G8398

• Diabetes with or without retinopathy2022F or 3072F

• Diabetes with retinopathy2021F

• Communication of macular edema and retinopathy to physician responsible for DM care

5010F and G8397 OR G8398 aloneOnce in a 12 month period - per reporting periodReport every time you use diagnosis and exam code

Diabetes with or without retinopathy2022F or 3072F

• Any of these diabetes diagnoses250.00-250.03, 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,

648.01-648.04

• Patients age 18-75 years old

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Diabetes with or without retinopathy

2022F Dilated eye exam in diabetic patient

OR

3072F Low risk of DR (normal exam last year)

(two other codes for imaging views of the retina exist for this measure, 2024F and 2026F, but we are making it simple and dilation is the recommended clinical care guidelines)

Diabetes with or without retinopathyExceptions

• 2022F

8P no reason for not performing dilated eye exam

• 3072F

No exceptions for this measure

Diabetes with retinopathy2021F

• Any of these six diagnoses codes– 362.01

– 362.02

– 362.03

– 362.04

– 362.05

– 362.06

• Patient age 18 years and older

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Diabetes with retinopathy

• 2021F

– Documented +/- macular edema and

level of diabetic retinopathy

• Exceptions

1P medical reason for not documenting

2P patient reason for not documenting

8P no reason for not documenting

Diabetes with retinopathy

• 5010FCommunicated presence or absence of macular edema

and the level of DR to physician responsible for the diabetic care

Exceptions

1P medical reason for not communicating

2P patient reason for not communicating

8P no reason for not communicating

Diabetes with retinopathy

G8397 Dilated macular exam performed

OR

G8398 Dilated macular exam not performed

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Diabetes Examples

1. DM –no DR, age 18-75: 2022F

2. DM +DR, age 18-75:2022F, 2021F, 5010F,G8397

3. DM – no DR, over age 75:no PQRS codes

4. DM +DR, over age 75:2021F, 5010F, G8397

Combined Examples

1. ARMD + DM, age 52:

2019F, 4177F, 2022F

2. ARMD + G (controlled), age 35:

2027F, 3284F

3. ARMD + G (uncontrolled) + DM age 72:

2019F, 4177F, 2027F, 0517F, 3285F, 2022F

4. G (uncontrolled) + DM with DR, age 72:

2027F, 0517F, 3285F, 2022F, 2021F, 5010F, G8397

5. ARMD + G (controlled) + DM, age 78:

2019F, 4177F, 2027F, 3284F

PQRS “Rules to live by”

1. Must file at least three different PQRS measures

2. Must file a PQRS measure on at least 50% of the claims whenever the examination code and diagnosis code indicates the need for a measure

3. File PQRS codes on EVERY CLAIM (with modifiers if needed) with the diagnosis code and the examination codes for that measure even if you did not perform the measure on that visit

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PQRS-Other Bits

1. Providing a little more timely feedback reports including interim reports

2. Created informal review for disputes on satisfactory PQRS a. 90 days from the release of report to request informal review through

the Quality Net Help Desk b. response given in writing within 60 daysc. decisions made will be final without further review or appeal

3. Retain claims-based reporting mechanism, the registry-based reporting mechanism, and the EHR-based reporting mechanism in 2012

4. BUT will consider significantly limiting the claims-based mechanism of reporting in future program years

PQRS Future• PQRS incentives through 2014

+0.5% for 2012- 2014

• PQRS payment adjustment beginning 2015

Minus 1.5% payment adjustment for 2015 if not using and

may be based on 2013 performance

Minus 2% payment adjustment for 2016 and up if not using

• AOA continues to fight to retain claims based

reporting, more timely performance reports and for

any penalties to be more closely linked to previous

year performance (ie 2015 impacted by performance

in 2014 and not by 2013 performance)

Additional PQRS Resources

Additional resources:

http://www.aoa.org/PQRI

http://www.cms.gov/PQRI

https://www.cms.gov/ERxIncentive

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AOA Resources

www.aoa.org/TPC

www.aoa.org/CPAG

www.aoa.org/EHR

ps@aoa.org

• Order Department 800-365-2219 or

orders@aoa.org

AOA Resources

AOA Website Sections Provide Information RegardingPrivate Insurers and Governmental Health Programs

– Third Party Center http://www.aoa.org/TPC– Clinical & Practice Advancement Group

http://www.aoa.org/CPAG

• Clinical Practice Guidelines• Frequently Asked Questions• Webinars and other online education for doctors and staff• Articles in AOA NEWS and the Journal of the AOA• AskTheCodingExperts@aoa.org

– Email your questions direct to an expert– Include AOA member’s name and state

– Paraoptometric Membership ps@aoa.org

AOACodingToday.com

• Online Coding and Reimbursement Tool

– Includes info from key national references• Medicare -Coverage determinations, RVUs, Correct Coding Initiatives

• CPT - Current Procedural Terminology

• ICD9 - International Classification of Diseases

• Special information about codes common to eye care (audit cautions, etc.)

• Improves Accuracy and Efficiency of Your Medical Billing, Making

It Easier to Submit “Clean Claims”

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$349New AOA Member Benefit

No Cost to AOA Members (June 2010)

New and Renewing AOA members

AOACodingToday.com

Web Based Resources

• AOA.ReimbursementPlus.com

– Subscription based resource, including coding information for procedures and diagnoses, accepted combinations of codes, compliance guidelines and reimbursement information specific to the insurers with which your office is contracted

– Popular program offered to AOA members at significant discount

AOA Resources Related to Coding

• Codes for Optometry—Two volumes $125

– AOA Order Department, 1-800-262-2210

• AMA Current Procedural Terminology, and

• AOA Codes for Optometry

– ICD-9 abridged for the eye

– Documentation Guidelines

– Correct Coding Initiatives from Medicare

– HealthCare Common Procedure Coding System (HCPCS) for Coding Materials in Medicare

– Companion readable CD, $25

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No Office is an Island

• Many resources available, but it’s up to you to seek the answers

• Don’t be shy about emailing your questions to AskTheCodingExperts@aoa.org . This is a free service to AOA Members and their staff.

• Watch for additional webinars and other AOA educational programs on medical records and coding coming this summer!

Handouts for This Course

http://www.aoa.org/coding

PQRS 2011

QUESTIONS???

AskTheCodingExperts@aoa.org

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American Optometric Association

Thank YOU!

Making Sense of PQRS- Making it Simple

Physician Quality Reporting System 2012

by

Rebecca H. Wartman OD