Disclaimers. Disclaimers. PQRS 2011 Made Easy 2/3/2011. Physician Quality Reporting System. Presented by Rebecca H. Wartman, O.D.

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1 Physician Quality Reporting System PQRS 2011 Made Easy Presented by Rebecca H. Wartman, O.D. Practice Advancement Committee Member, Clinical and Practice Advancement Group American Optometric Association Disclaimers This presentation is: 1. 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. 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 This presentation is: 6. A 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 for providers. For additional information visitthethe Medicare Learning Network s web page at 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. 1

2 2011 PQRI=PQRS Just when you thought you had it Physician Quality Reporting Initiative = PQRI Physician Quality Reporting System= PQRS Physician Quality Reporting System 2011 PQRS History Overview Pay for Reporting Voluntary for Tax Relief and Health Care Act of 2006 (TRHCA) Authorizes financial incentive for professionals by reporting quality data Medicare, Medicaid, and SCHIP Extension Act of2007 (MMSEA) Continued authorization for PQRI in Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) Expanded bonus payments through % bonus The Affordable Care Act (ACA) of 2010 Created a 1.0% bonus in 2011 and a 0.5% bonus in For those who do not report, reduces Medicare payments by 1.5% in 2015 and by 2.0% in 2016 PQRS Reporting Reported with Quality Data Codes (QDCs) HCPCS G codes used: measures without published CPT II codes measures required to share CPT II codes CPT II codes 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 PQRI 2

3 PQRS Form and Manner of Reporting Paper based CMS 1500 claims Electronic based using ASC X 12N Health Care Claim Transaction (Version 4010A1). Must be reported on the same claim as CPT I No registration is required to participate Still strictly voluntary for 2011 PQRS Form and Manner of Reporting Other reporting methods Registry reporting no clinical registries specific to eye care Measures groups no groups appropriate for optometry Electronic Health Records Reporting no measures specific to eye care Registry reporting may replace claims based reporting in future EHR reporting may replace other reporting methods in future AOA is: investigating potential development of clinical eye care registry reviewing current registries for reporting some measures by optometry actively reviewing EHR reporting mechanisms for future use Satisfactory PQRS Reporting Claims 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 3

4 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 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 PQRS Bonus Payment 1.0% bonus payment for 2011 Bonus paid on all Medicare allowable 2011 charges Includes TC of diagnostic services Bonus paid to holder of TIN (Tax Identification Number) 4

5 PQRS Basics Numerator Appropriate QDC Code (s) Denominator CPT I codes Any appropriate diagnosis indicated Additional factors such as age and frequency Understanding PQRS Analysis Analysis by individual NPI under each TIN Must have and correctly use individual NPIs Requires individual d providers identified d Separate analysis for each TIN Must reach the 3 measure 50% threshold PQRI (S) Feedback Reports 2007 PQRI quality reports June PQRI quality reports in October PQRI quality reports in November PQRS quality reports in???? 2011 Reports by NPI for each TIN Access reports via IACS or Contractor/Carrier by NPI If report available will be listed at: 5

6 2009 PQRI How did we do? Ophthalmology 6,514/18,943 = 34.4% Optometry 5,464/34,660 = 15.8% All MD/DO 119,541/667,340 = 17.9% Non MD/DO 44,369/420,505 = 10.6% PQRS Participation Considerations New Participating Physician Directory (Medicare.gov) Listing who attempted PQRI for Listing i who successfully reported for 2009 This initiative will help your doctor and Medicare provide the highest level of quality of care for people like you, who have Medicare. Medicare greatly appreciates that your doctor has chosen to join this important initiative Physician Compare Web site CMS will post names of providers who: 1. Submit data on the 2011 PQRS quality measures through one of the reporting mechanisms 2. Meet one of the proposed satisfactory reporting criteria of individual measures or measures groups for the 2011 PQRS 3. Qualify to earn a PQRS incentive payment for covered professional services furnished during the applicable 2011 PQRS reporting period Eventually will report performance information, including the measures collected under PQRS 6

7 PQRI 2009/2010 Summary of Reporting AMD: Counseling on Antioxidant Supplements (#140:4177F) had one of the highest percentage of valid reports for 2009 First quarter 2010 error rate breaks down as follows: 3% were mismatched for age 5% were incorrect procedure codes 10% were incorrect diagnosis codes 3% had both incorrect procedure & diagnosis codes 2010 PQRI Review of Program 2010 payments will be mid to late measures for measures dealing with eye care (3 measures only for surgeons) 1 technology code 5 other measures could be used by OD s Separate E prescribing measure 2% bonus (Not PQRI) 2010 reporting: 1/1/2010 to 12/31/2010 7/1/2010 to 12/31/ PQRS 9 of the 10 eye care measures were retained for 2011 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 measures Cataract codes for surgeons Measure 191 and 192 were retained, 139 was deleted 7

8 2011 PQRS Retirement of 5 measures: : Preventive Care and Screening: Inquiry Regarding Tobacco Use : Preventive Care and Screening: Advising Smokers and Tobacco Users to Quit : Melanoma: Follow Up Aspects of Care : Cataracts: Comprehensive Preoperative Assessment for Cataract Surgery with Intraocular Lens (IOL) Placement : Pediatric End Stage Renal Disease (ESRD): Plan of Care for Inadequate Hemodialysis 194 measures 5 new measures for claims and registry reporting 11 new registry-only measures 4 new measures for EHR-based reporting only 20 EHR measures 14 measures groups- Includes 1 new measures group (asthma) 2011 PQRS 1% bonus (total allowed charges for Medicare Part B provided for reporting period) Extra 0.5% incentive payment if provides data on quality measures through a Maintenance of Certification Program Optometry not eligible until maintenance of board certification program begins EHR and Registry reporting: 3 measures 80% of time Claims based reporting threshold reduced Successful reporting: 3 measure 50% of time 2 Reporting periods for claims or registry 1/1/11 12/31/11 7/1/11 12/31/11 Measure group and EHR reporting rules are different PQRS 2011 Claims must reach National Claims History file by February 24, 2012 to be included in the analysis File end of year claims in timely manner 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 8

9 PQRS 2011 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: Physician Quality Reporting System PQRS Three Diagnoses To Think About: Age Related Macular Degeneration Primary Open Angle Glaucoma Diabetes: Insulin and Non insulin Dependent ANY OF THESE THINK PQRS Physician Quality Reporting System PQRS If you report an evaluation & management code or OR Ifyou report a general ophthalmic service code 92004,92014, 92002, ANY OF THESE CODES THINK PQRS Other E&M codes eligible as well but will not discuss those in this forum 9

10 Physician Quality Reporting System PQRS If you have the diagnosis and the examination code: The only step left is to add the PQRS code Must add the PQRS code to every Medicare claim If you do this, you should earn your bonus! Physician Quality Reporting System PQRS Rule of thumb: USE PQRS EVERY TIME YOU HAVE DIAGNOSIS AND ENCOUNTER CODE (with modifiers if needed) OR WILL COUNT AGAINST YOU! Exceptions Modifiers If measure cannot be completed You must still report to be counted Use modifiers 1P: medical reason 2P: patient reason 8P: other reason 10

11 Physician Quality Reporting System PQRS Let s break kit down by disease Age Related Macular Degeneration Any of these three diagnoses Macular Degeneration, NOS Macular Degeneration, non exudative Macular a Degeneration, e exudative e 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 or once per reporting period BUT YOU MUST REPORT EVERY TIME 11

12 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 d 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 or 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 12

13 Glaucoma Primary Open Angle Two PQRS measures to be used (12,141): 2027F and 3284F or 0517F+3285F Any of these four diagnoses Open angle glaucoma, unspecified Primary open angle glaucoma Low Tension Glaucoma Residual Open Angle Glaucoma Patient age 18 years and older Glaucoma Two different reporting options Controlled IOP 2027F and 3284F Uncontrolled diop 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 or reporting period Report every time you use diagnosis and exam code 13

14 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 preintervention 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 examples recheck of IOP at specified time change in therapy perform additional diagnostic evaluations perform additional diagnostic evaluations monitoring per patient decisions unable to achieve due to health system reasons referral to a specialist 14

15 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 retinopathy 2022F or 3072F Diabetes with ihretinopathy 2021F Communication of macular edema and retinopathy to physician responsible for DM care 5010F and G8397 OR G8398 alone Once in a 12 month period or per reporting period Report every time you use diagnosis and exam code Diabetes with or without retinopathy Any of these diabetes diagnoses , , , , , , , , , , 357.2, , , Patients between age years old 15

16 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 standard of care) Diabetes with or without retinopathy Exceptions 2022F 8P no reason for not performing dilated eye exam 3072F No exceptions for this measure Diabetes with retinopathy Any of these six diagnoses codes Patient age 18 years and older 16

17 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 5010F Communicated 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 17

18 Diabetes Examples 1. DM no DR, yo: 2022F 2. DM +DR, yo: 2022F, 2021F, 5010F,G DM no DR, over 75 yo: no PQRI 4. DM +DR, over 75 yo: 2021F, 5010F, G8397 Combined Examples 1. ARMD + DM, 52yo: 2019F, 4177F, 2022F 2. ARMD +G(controlled), 35yo: 2027F, 3284F 3. ARMD + G(uncontrolled) + DM 72yo: 2019F, 4177F, 2027F, 0517F, 3285F, 2022F 4. G(uncontrolled) + DM with DR, 72yo: 2027F, 0517F, 3285F, 2022F, 2021F, 5010F, G ARMD + G(controlled) + DM, 78yo: 2019F, 4177F, 2027F, 3284F 18

19 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 when 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 2011 Electronic Prescribing 1% Incentive Payment (not available if receiving 2011 Medicare EHR Incentive) Reporting Period Jan 1, 2011 Dec 31,2011 Reporting Mechanisms Claims, qualified registry, qualified EHR Report for at least 25 unique erx events G8553: At least one prescription created during the encounter was generated and transmitted electronically using a qualified erx system 2011 Electronic Prescribing 2012, 1 % reduction if do not ERx in payment adjustment reporting period 1/1/2011 6/30/2011 Hardship reporting codes to be report at least one time on a denominatoreligible claim during payment adjustment reporting period G8642: The eligible professional practices in a rural area without sufficient high speed internet access and requests a hardship exemption from the application of the payment adjustment under section 1848(a)(5)(A) of the Social Security Act G8643: The eligible professional practices in an area without sufficient available pharmacies for electronic prescribing and requests a hardship exemption from the application of the payment adjustment under section 1848(a)(5)(A) of the Social Security Act G8466: The eligible professional does not have prescribing privileges. If this code is utilized, the eligible professional may not be considered for a payment adjustment 19

20 PQRS Future 1. Provide timely feedback reports including interim reports 2. Create 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 would be given in writing within 60 days c. decisions made would be final without further review or appeal 3. Retain claims based reporting mechanism, the registrybased reporting mechanism, and the EHR based reporting mechanism in BUT will consider significantly limiting the claims based mechanism of reporting in future program years PQRS Future PQRS incentives through % for % for PQRS payment adjustment beginning 2015 Minus 1.5% payment adjustment for 2015 if not using Minus 2% payment adjustment for 2016 and up if not using Develop plan to integrate reporting under the PQRS and reporting under EHR Incentive Program by 1/1/2012 Timely feedback Additional PQRS Resources Additional resources:

21 AOA Resources Order Department or AOA Resources AOA Website Sections Provide Information Regarding Private Insurers and Governmental Health Programs Third Party Center Clinical & Practice Advancement Group ClinicalPractice Guidelines Frequently Asked Questions Webinars and other online education for doctors and staff Articles in AOA NEWS and the Journal of the AOA 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 C tp d lt i l 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 21

22 AOACodingToday.com $349 New AOA Member Benefit No Cost to AOA Members (June 2010) New and Renewing AOA members 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 AOA Order Department, Current Procedural Terminology ICD 9 CM International Classification of Diseases (abridged for eye care) The CMS Documentation ti Guidelines for the Evaluation and Management Services The Healthcare Common Procedure Coding System The Correct Coding Initiative Edits for common eye care codes 22

23 No Office is an Island Many resources available, but it s up to you to seek the answers Don t be shy about ing 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 PQRS 2011 QUESTIONS??? AskTheCodingExperts@aoa.org 23

24 American Optometric Association Thank YOU! PQRS 2011 MADE EASY Q by Rebecca H. Wartman OD 24