Ophthalmology and Optometry Coding Alert

When ophthalmologist doesn't meet measure, P modifier ensures compliance.

Ophthalmology practices who want to recoup a bonus from Medicare can choose to participate in the Physician Quality Reporting Initiative (PQRI) again -- this time with a higher rate of return.

The basics: In 2008, the PQRI bonus was 1.5 percent for practices that met the measures. In 2009, PQRI pays a 2 percent bonus, relays Eli Berg, MD, FACEP, CEO of MRSI, a billing company in Woburn, Mass. Here's a primer on participating in this program.

The first step in PQRI participation is focusing your reporting on measures your ophthalmologist will often meet. According to CMS, the 2009 PQRI includes 153 reporting measures; however, only a handful will be relevant to ophthalmologists.

You will need to do a little extra coding for PQRI participation, relays Caral Edelberg, CPC, CCS-P, CHC, president of Medical Management Resources for TeamHealth in Jacksonville, Fla. "There are specific PQRI quality-data codes associated with each of the PQRI measures," she says. The PQRI quality-data codes are CPT Category II codes, located in the back of CPT 2009 and in Appendix H, where CPT lists the measures alphabetically by clinical condition or topic. (See "2009 PQRI Eye Care Measures" on page 13.)

You only need to report on three of the measures in at least 80 percent of cases to qualify. Ophthalmologists who meet this threshold will get a 2 percent bonus on all total allowed charges for covered Medicare services.

Do this: Check the Medicare PQRI guidelines, available at www.cms.hhs.gov/pqri. For each quality measure, the 2009 PQRI Measure Specifications Manual lists the CPT codes and the linked diagnosis codes. If you report a particular CPT and ICD-9 code together, you can determine if the quality measure applies. Then you report on test results or other measures using Category II or G codes.

Follow these steps on each of your claims to increase PQRI reporting success:

• Review documentation to determine if treatment is consistent with the PQRI measure.

• Assign the CPT and ICD-9 codes as you would normally for the claim.

• Check to make sure your ICD-9 and CPT codes line up with the measure's requirements

• Assign the appropriate Category II code, and any modifiers that you might need.

Example: The ophthalmologist sees a patient during his ongoing management of primary open-angle glaucoma (POAG), and performs an optic nerve head examination. Report the appropriate level office visit with 99211-99215 or 92012-92014, and the appropriate ICD-9 code -- 365.01 (Borderline glaucoma; open angle with borderline findings) or 365.1x (Open-angle glaucoma ...) -- and add Category II code 2027F (Optic nerve head evaluation when performed) to report the quality measure.

For the scanning laser, report 92135 (Scanning computerized ophthalmic diagnostic imaging, posterior segment [e.g., scanning laser], with interpretation and report, unilateral) with the established-patient E/M code (99212-99215) or eye exam code (92012 or 92014). Exception: The Correct Coding Initiative bundles 92135 into 99211 with modifier indicator "1."You can only report those two codes together with an appropriate modifier, such as 59 (Distinct procedural service).

If a patient's condition mirrors a PQRI measure, but the physician does not meet all the treatment requirements during the visit, you can still report the encounter to PQRI. Just remember to append a P modifier to the Category II code, says Sandra Pinckney, CPC, coder at a practice in Grand Rapids, Mich.

These modifiers, which explain to Medicare why the physician did not meet the PQRI measure, are:

• 1P -- Measure not met for medical reasons.

• 2P -- Patient declined treatment associated with measure.

• 3P -- Measure not met for system reasons.

• 8P -- Measure not met, reason not specified.