Ophthalmology and Optometry Coding Alert

CMS shows which issues sidelined these practices.

Most practices would agree that a 57.2 percent success rate isn't overly impressive -- but that's exactly what CMS found in its recent analysis of PQRI submissions. So how are your fellow ophthalmology coders faring in reporting eye care measures?

Almost 43 percent of the quality data codes (QDCs) that practices submitted to CMS were ineligible for the Physicians Quality Reporting Initiative (PQRI) bonus because physicians reported them improperly, CMS noted in its Feb. 13 report, "Quality-Data Code Submissions Error Report." The report analyzed PQRI submissions over the first three quarters of 2008.

For 2009, the PQRI incentive payment is two percent of your physician's allowed charges under the Medicare physician fee schedule. If you'd like to keep that two percent flowing into your practice, avoid these errors that CMS found:

1. Missing NPI. CMS notes that 97,131 of the QDC submissions were missing their national provider identifier (NPI). This happened rarely in the eye care measures; less than 1 percent for the five measures ophthalmologists could report in 2008 were missing NPIs. Among the worst offenders in this category were claims for measure 112 (Screening mammography), which lacked an NPI in 3.5 percent of QDCs.

2. Wrong HCPCS code. A whopping 15.6 percent of QDC submissions (nearly 3 million claims) had incorrect HCPCS codes on them.

One of the most common errors in this category occurred with measure 130 (Documentation of current medications). CMS noted that 74.6 percent of claims for this measure featured an incorrect HCPCS code.
Also at a high risk of errors was measure 46 (Medication reconciliation), with 69 percent of claims featuring an incorrect HCPCS code.

Among the eye-care specific measures, 9.4 percent of claims for measure 14 (Dilated macular examination) featured the wrong HCPCS code.

You don't want to face a double-whammy -- a denied claim due to a wrong code, as well as lost PQRI bonus money for the same reason, says Carla Whitmire with Strategic Coding Systems in Little Rock, Ark. Therefore, double-check your code selection before you submit your claim.

3. Wrong diagnosis. CMS found that 14.9 percent of QDC submissions included incorrect diagnosis codes. 

A prime offender in this category was measure 19 (Diabetic retinopathy: Communication with the physician managing ongoing diabetes care), which had incorrect diagnosis codes 38.2 percent of the time.

Keep in mind: CMS also looks for errors in other aspects of QDC submissions, says Jay Neal, an Atlanta-based coding consultant. "Auditors look for discrepancies in patient-age mismatches, as well as patient-gender mismatches."

For instance, CMS showed a 32.5 percent error rate in patient-gender mismatches for measure 117 (Dilated eye exam in diabetic patient).

To read the errors, visit www.cms.hhs.gov/PQRI/Downloads/2008QDCError3rdQuarter.pdf.

To learn more about the PQRI eye care measures, see "Share in Bonus Payment With 3 New Ophthalmic Measures" in Ophthalmology Coding Alert, Volume 12, Number 2