Ophthalmology and Optometry Coding Alert

Key: Educate your staff and perform a test run soon

Your time to prepare for the Physician Quality Reporting Initiative (PQRI) is quickly running out. So now is the time to figure out how to bill enough category II quality codes to receive the 1.5 percent bonus from Medicare.

Bad news: If you start too long following the July 1 launch date, you probably won't report enough quality codes to make the 1.5 percent bonus, CMS officials have said, and you will be limited to a payment cap determined by the number of quality measures you do report.

How it works: Every physician who reports on quality measures at least 80 percent of the time that they apply to their eligible patients will receive a bonus next year. The bonus will consist of up to 1.5 percent of the total allowable amount each doctor billed Medicare from July 1 to Dec. 31, 2007.

The bonus will apply to all allowable charges, including deductibles and co-payments. Bonus calculations will not include physician laboratory or physician-administered drug charges, and there will be no beneficiary co-insurance requirement for quality measures you report.

On the other hand, as indicated above, CMS will apply a -cap- to the bonus for doctors who do not report a sufficient number of quality measures, and there will be no appeal process for physicians to question their bonus payments.

Good news: Let our expert guidance set you on the right path to ensure your physician gets the bonus money he deserves.

Focus on Specific Quality Measures

Your first step with PQRI is to determine which quality measures you may be able to report. CMS has posted a list of the 74 quality measures, along with detailed specifications, at www.cms.hhs.gov/pqri. You should consider the conditions your practice treats, and the type of care your practice provides: preventive, chronic or acute.

Key: Choose measures that have a large impact on your practice's quality improvement. If you pick three quality measures that your practice reports infrequently, you risk coming under the -cap- on bonus payments, and you won't receive the full 1.5 percent bonus payment.

Example: For ophthalmology, you-ll likely want to home in on the following eight measures, says Rita Knapp, CPC, chief compliance officer and senior billing specialist at Abrams Eyecare Associates in Indianapolis:

- #12 -- Primary Open Angle Glaucoma: Optic Nerve Evaluation

- #13 -- Age-Related Macular Degeneration: Age-Related Eye Disease study (AREDS) Prescribed/ Recommended

- #14 -- Age-Related Macular Degeneration: Dilated Macular Examination

- #15 -- Cataracts: Assessment of Visual Functional Status

- #16 -- Cataracts: Documentation of Pre-Surgical Axial Length, Corneal Power Measurement and Method of Intraocular Lens Power Calculation

- #17 -- Cataracts: Pre-Surgical Dilated Fundus Evaluation

- #18 -- Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level of Severity of Retinopathy

- #19 -- Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care.

Associate Measures With the Correct CPT and  ICD-9 Codes

To help you prepare, CMS released specifications at www.cms.hhs.gov/PQRI/Downloads/Specifications _2007-02-04.pdf. For each quality measure, the document 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.

If the measure doesn't apply, you can use the 1P (Medical reasons), 2P (Patient reasons) and 3P (System reasons) modifiers to explain why the measure didn't apply. Alternatively, you can apply modifier 8P (Unspecified reasons), says Maggie M. Mac, CMM, CPC, CMSCS, consulting manager for Pershing, Yoakley & Associates in Clearwater, Fla.

Pointer: If more than one physician treats the same patient, each doctor can report on the same quality measure for that patient, CMS officials said. You should only report on quality measures that fit with your physician's specialty and with particular eligible patients. But if your doctors provide care outside of their specialty, such as managing a patient's other problems, you may report those quality measures, as well. 

You-ll report some measures only once each year, so you would not need to report them for every encounter after you report them the first time. But you will not be penalized for reporting measures that you-re supposed to report only once per year if you mistakenly report them again.

Tip: When you-re figuring out which claims to match up with the quality reporting codes, you should look at both primary and secondary ICD-9 diagnosis codes, experts say.

Start now: One way to prepare for the PQRI expense is to educate your staff on the importance of -accurate and complete ICD-9 coding,- says Collette Shrader, compliance and education coordinator with Wenatchee Valley Medical Center in Wenatchee, Wash. Getting ICD-9 codes right is important at any time, but it's especially important for the PQRI.