AOA expert helps make PQRS simple

April 5, 2012

By Rebecca H. Wartman, O.D., AOA Practice Advancement Committee

The Physician Quality Reporting System (PQRS, or formerly PQRI) has been in existence since 2007. The past five years have seen an evolution in this program. Luckily for optometry, there have been few changes in the past two to three years, making it easier for us to become successful in reporting. 

Successful reporting means recognition for providing quality care for the individual doctor and for the optometric profession, as well as more dollars in the coffers of the optometrist.

The 2012 PQRS measures for optometry have few changes from 2011 reporting requirements. To be successful in reporting for 2012, the provider must choose at least three PQRS measures and report them consistently on at least 50 percent of the appropriate claims.

However, this does not mean a provider needs to file three different PQRS measure on each claim.  

For PQRS reporting, there are three different diseases that should be of concern to the optometrist: age-related macular degeneration, glaucoma and diabetes. 

The only examination codes of consequence when considering PQRS reporting are the evaluation and management (E&M) codes to report examinations, including 99201-99205 and 99212-99215 (and other E&M codes such as nursing home or rest home E&M codes) and/or the general ophthalmic examination codes (92002, 92012, 92004, and 92014).  Other eye care procedures do not trigger opportunities for reporting.

Once a provider has a patient with traditional Medicare or Railroad Medicare AND that patient has one of the three diseases AND the patient is billed using an E&M code or a general ophthalmic visit code, then a PQRS measure should be considered.

The bonus payment for successfully participating in the 2012 PQRS will be 0.5 percent of a practitioner’s entire Medicare allowables filed for 2012.

The bonus applies to any and all Medicare claims filed by a provider, with or without a PQRS measure attached.

Why should optometrists be participating in the PQRS program for a small bonus payment? Consider what the Centers for Medicare & Medicaid Services (CMS) is telling our patients. On the Physician Compare website, Medicare lists the practitioners who have successfully participated in PQRS for 2010 with the following statement: “This professional chose to take part in Medicare’s Physician Quality Reporting System and reported quality measure information satisfactorily for the year 2010.”

The CMS further states, “A physician or other health care professional can choose whether to report quality information to Medicare under the Physician Quality Reporting System. Medicare believes that reporting quality information by professionals is an important means to improve the quality of care provided to Medicare beneficiaries.” 

This last statement gives the distinct impression that providers who participate in this program provide better care than those providers who do not participate. Patients are reading this information and making judgments on the quality of care. 

Eventually, the CMS will provide reports to patients on actual performance under PQRS.

How did optometry perform in 2010? In 2010, 1,381,276 quality data codes (QDCs) were submitted by optometry, with 81.15 percent of the codes correctly applied. Compare this to 5,119,625 codes submitted by ophthalmology with 87.42 percent of the codes correctly applied.  

Overall, the optometrists who reported PQRS codes were successful. The majority of the errors were from inappropriate diagnosis codes being submitted with PQRS codes.  

The numbers reported to date for the 2011 PQRS year just ended are very similar to the 2010 numbers. 

However, more optometrists should earn the PQRS bonus because 2011 was the first year the threshold for successful reporting dropped from 80 percent correct to 50 percent correct submission of at least three measures. 

The payments for the 2011 PQRS will not be sent until sometime in the third quarter of 2012 (if past payment times are any indication).

PQRS 2012 measure details

Nine eye care measures were retained for 2012, and two new measures were added. Optometry only needs to be concerned with seven of these measures.

  • 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 percent OR Documentation of a Plan of Care

Measure numbers refer to the order of the measures listed in the original CMS documents and are not meant to be used to report the measures.

The other four PQRS codes are registry-only codes and are not really meant for use by optometry. The retained codes are cataracts codes for surgeons (#191 and #192). The new PQRS codes are cataract outcomes by patient report (#303 and #304).

Details of the PQRS 2012 codes specific to eye care by disease

Again, all of the eye care-specific PQRS measures are applied when the provider is coding an evaluation and management code (99211-99205, 99212-99215) or a general ophthalmic visit code (92002-92014). 

The evaluation and management codes for nursing home, rest home and others are also included. 

The PQRS measures do not apply to any special ophthalmic service codes such as scanning laser, visual fields, and photography.

Macular Degeneration

There are two measures for the diagnosis of macular degeneration. If any of the following three AMD diagnoses are coded, the provider may use one or both of these measures. The patient also needs to be age 50 or older.

  • 362.50 Macular Degeneration, NOS
  • 362.51 Macular Degeneration, non-exudative
  • 362.52 Macular Degeneration, exudative

Measure #14, using the QDC 2019F, indicates the provider had a dilated view of macula AND documented whether macular thickening and hemorrhages were present or not present.

The provider must dilate and record the finding once per 12-month period or once per reporting period.

However, the QDC must be used on every claim submitted for the AMD diagnosis, even if the dilated macular examination was performed during a prior patient visit.

The exceptions for 2019F are:

  • 1P: medical reason for no dilated macula view
  • 2P: patient reason for no dilated macula view
  • 8P: other reason for no dilated macula view

An exception would be used only if the provider could not complete the measure requirements for the reason attached to the exception. The exception is indicated using the 1P, 2P or 8P as a modifier to the QDC.

Measure #140, using the QDC 4177F, indicates the provider discussed the pros and cons of the Age-Related Eye Disease Study (AREDS) formulation of antioxidant supplements and made proper recommendations for individual and documented discussion per the AREDS report (www.aoa.org/PQRS).

This discussion and documentation of recommendations must occur once per 12-month period or once per reporting period for each unique patient.

However, the QDC must be used on every claim submitted for the AMD diagnosis even when the AREDS discussion occurred during a prior patient visit.

The only exception for 4177F is 8P: no reason for not discussing AREDS.

Primary Open-Angle Glaucoma

There are two measures for the diagnosis of glaucoma. If any of the following glaucoma diagnoses are coded, the provider may use one or both of these measures. The patient must be age 18 or older.

  • 365.10 Open-Angle Glaucoma, unspecified
  • 365.11 Primary Open-Angle Glaucoma
  • 365.12 Low-Tension Glaucoma
  • 365.15 Residual Open-Angle Glaucoma
  • 365.70-365.74 (new codes used in conjunction with regular glaucoma diagnoses)

Measure #12, using the QDC 2027F, indicates the provider viewed optic nerve with or without dilation. The provider must document the results of the optic nerve view once per 12-month period or once per reporting period for each unique patient. However, the QDC must be used on every claim submitted for the glaucoma diagnosis even when the optic nerve view occurred during a prior patient visit.

The exceptions for 2027F are:

  • 1P medical reason for not viewing optic nerve
  • 8P no reason for not viewing optic nerve

Measure #141 has three different codes to consider with several different code combinations. QDC 3284F is used to indicate when the intraocular pressure (IOP) was reduced 15 percent or more from pre-intervention levels. QDC 3285F is used when IOP was NOT reduced 15 percent from pre-intervention levels AND 0517F is added to indicate a plan of care to get IOP reduced is in place.

The exceptions are as follows:

  • 3284F: 8P IOP not documented, no reason given
  • 3285F: No exceptions because a practitioner would use 3284F- 8P if the IOP was not measured.
  • 0517F: 8P no plan of care documented to reduce the IOP.

For QDC 0517F, a plan of care might consist of a plan to recheck IOP at specified time, a change in therapy, a plan to perform additional diagnostic evaluations, monitoring of IOP per patient decisions, indication that the target IOP was unable to be achieved due to health system reasons or a referral to a specialist. 

Again, any plan of care should be documented in the patient record.

Primary open-angle glaucoma codes

  • Controlled IOP: Use 3284F
  • Uncontrolled IOP: Use 3285F and 0517F
  • No IOP measured: Use 3284F-8P alone
  • Uncontrolled IOP but no plan of care: Use 3285F and 0517F-8P


Three different measures are in place for a patient with diabetes, either insulin-dependent or non-insulin-dependent that include measures #18, #19 and #117.

Measure #18, using QDC2021F, is used only with diabetes when retinopathy is present. 

The provider must perform a dilated macular or fundus examination and document the presence or absence of macular edema and the level of diabetic retinopathy. This measure is only used when there is diabetic macular edema or diabetic retinopathy. The patient must be 18 years or older. 

The following diabetic retinopathy diagnoses are the only ones applicable to this measure:

  • 362.01 Background Diabetic Retinopathy
  • 362.02 Proliferative Diabetic Retinopathy
  • 362.03 Nonproliferative Diabetic Retinopathy, not otherwise specified
  • 362.04 Mild Nonproliferative Diabetic Retinopathy
  • 362.05 Moderate Nonproliferative Diabetic Retinopathy
  • 362.06  Severe Nonproliferative Diabetic Retinopathy

The exceptions for 2021F are as follows:

  • 1P medical reason for not documenting macular edema and diabetic retinopathy
  • 2P patient reason for not documenting macular edema and diabetic retinopathy
  • 8P no reason for not documenting macular edema and diabetic retinopathy

Measure #19 uses three different QDCs. QDC 5010F indicates the provider communicated the presence or absence of macular edema and the level of diabetic retinopathy to physician responsible for the diabetic care. The same list of diabetic retinopathy diagnoses listed for measure #18 applies to this measure. Again, the patient age range is 18 years or older for this measure. In addition, the provider needs to indicate if a dilated macular or fundus examination was performed.

The QDC options for this information are G8397, indicating the dilated macular or fundus exam was performed, OR G8398, indicating the dilated macular or fundus exam not performed.  

There are no exceptions for G8397 and G8398. The exceptions for 5010F are:

  • 1P medical reason for not communicating
  • 2P patient reason for not communicating
  • 8P no reason for not communicating

Measure #117 uses one of four QDCs to indicate a dilated diabetic examination was performed. This measure is only used for patients age 18 to 75. And this measure is used for an expanded list of diagnoses. Any of these diabetes diagnoses apply to this measure:
250.00-250.03, 250.10-250.13, 250.20-250.23, 250.30-250.33, 250.40-250.43, 250.50-250.53, 250.60-250.63, 250.70-250.73, 250.80-250.83, 250.90-250.93, 357.2, 362.01-362.07, 366.41, 648.01-648.04.

Providers should use one of the following QDCs to report this measure: 

  • QDC 2022F is used to indicate a dilated eye exam was performed in a diabetic patient. 
  • QDC 3072F would be used when the patient is at low risk for diabetic retinopathy (meaning that patient had a normal examination without diabetic retinopathy within the last year). 

Two other codes for imaging views of the retina exist for this measure, but are not commonly used by eye care providers. QDC 2024F would be used for reporting that seven standard field stereoscopic photos with interpretation by an ophthalmologist or optometrist were documented and reviewed. QDC 2026F would be used to indicate eye imaging was validated to match diagnosis from seven standard field stereoscopic photos results that were documented and reviewed. As most optometrists perform dilated diabetic examinations, 2022F would be the most common QDC used to report this measure.

When thinking about the seven QDC measures applicable for eye care providers, it is helpful to consider these measures by disease.

For example, when seeing a patient with AMD who is 50 or older, a provider would typically perform a dilated macular examination at least yearly and discuss the AREDS formulation of supplements at least yearly. Thus, the provider could easily code 2019F and 41277F together for all the AMD patients each and every time this AMD diagnosis is coded and sent to Medicare.
 Similarly, with a glaucoma patient who is 18 years or older, the provider typically would perform an optic nerve evaluation at least yearly and would measure the intraocular pressure at least yearly. In addition, when the IOP is not controlled, a provider would typically develop a plan to reduce the IOP to an acceptable level. Coding 2027F and 3284F for a controlled glaucoma patient or 2027F, 0517F and 3285F together for an uncontrolled glaucoma patient would not be difficult.

Diabetic patients present a little more challenge in properly applying the PQRS measures. Age is a key to properly applying these measures. 

Any diabetic patient, with or without diabetic retinopathy, between 18 and 75 years, would have QDC 2022F coded to indicate a dilated eye examination was performed (assuming the provider would typically dilate all diabetic patients yearly).  

In addition, when diabetic retinopathy with or without macular edema is found, the provider would use 2021F to indicate a dilated macular or fundus examination was performed. Use 5010F to indicate a report was sent to the provider caring for the diabetes along with G8397 to again indicate the dilated macular or fundus examination was performed.

Note that it is the best practice for an eye care provider to communicate with all physicians caring for the diabetic patient, but PQRS only addresses this report when diabetic retinopathy and/or macular edema are found. Also note any and all exceptions to the examples above for all the measures would be reported using the appropriate modifiers listed earlier in this article.

PQRS is not difficult. Consistency is the key to participating and earning the bonus payments and avoiding penalties in the future if a provider does not participate. 

Providers should use the summary sheet developed by the AOA when seeing patients and coding examinations to make the process easier (www.aoa.org/PQRS).

Happy coding…

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