Optometry Coding & Billing Alert

When you don't meet the measure, P modifier ensures compliance.

Optometrists 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 the optometrist will often meet. According to CMS, the 2009 PQRI includes 153 reporting measures; however, only a handful will be relevant to optometrists.

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 "Keep These 2009 PQRI Eye Care Measures Handy" on page 11.)

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

"Since you have to report an unknown minimum number to qualify, I would recommend selecting the four most common codes to a doctor's practice, and certainly at least the three most common codes," advises David Gibson, OD, FAAO, a practicing optometrist in Lubbock, Texas.

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 optometrist 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 [glaucoma suspect]; 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).

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 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 -- Performance measure exclusion modifier due to medical reasons

• 2P -- ... due to patient reasons

• 3P -- ... due to system reasons

• 8P -- Performance measure reporting modifier-- action not taken, reason not otherwise specified.