Optometrists enter crucial year with PQRS: 2013

March 11, 2013

By Rebecca H. Wartman, O.D.

Claim successSince the Physician Quality Reporting System (PQRS) was first introduced in 2007 it has continually evolved, bringing us to this pivotal year. While there are only a few minor changes to the program for 2013, it is an important year. Any provider who does not participate in 2013 will be penalized in 2015. (See “PQRS reporting required in 2013 to avoid 2015 payment cuts” in the January edition of AOA News.) Successful reporting means recognition for providing quality care for the individual doctor and for the optometric profession, as well as compensation for optometrists and avoidance of the 2015 penalties.

For successful reporting in 2013, the provider must choose at least three PQRS measures and report them consistently on at least 50 percent of the appropriate claims. This does not mean a provider needs to file three different PQRS measures on each claim.

To make PQRS 2013 reporting simple, there are only three diseases of concern to the optometrist: age-related macular degeneration, glaucoma and diabetes. (See diagnosis chart.)

The general ophthalmological examination codes (92002, 92012, 92004, and 92014) and/or the evaluation and management (E&M) codes to report examinations (99201-99205 and 99212-99215, including nursing home or rest home E&M codes, etc.) are the only examination codes of concern when reporting 2013 PQRS measures. Other eye care procedures do not trigger opportunities for reporting.

The 2013 PQRS codes are reported only on patients with traditional Medicare or Railroad Medicare, and who have one or more of the three diseases, and whose visit is billed using an E&M code or a general ophthalmic visit code.

Another important key to reporting for PQRS 2013 is to link each Quality Data Code (QDC) with only one applicable diagnosis even when more than one diagnosis code is applicable to the QDC.

The bonus payment for successfully participation in the 2013 PQRS will be 0.5 percent of your entire Medicare allowables filed for 2013. The bonus applies to any and all Medicare claims filed by a provider whether or not the visit is eligible for the addition of a PQRS measure code.

Why participate?

Why should optometrists participate in the PQRS program?

The primary reason for 2013 would be to avoid the 1.5 percent reduction in all your Medicare reimbursements for 2015. The second reason for participating is earning the 0.5 percent bonus for all your Medicare payments for 2013: more money is more money.

Finally, 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 2011 (or 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 2011 (or 2010).” Further, the CMS states: “A physician or other healthcare 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.”

Whether true in reality, this last statement gives the distinct impression that providers who participate in this program provide better care than those providers who do not participate. Your patients are reading this information and making judgments on the quality of your care. Eventually, the CMS will be providing reports to your patients on your actual performance under PQRS.

How did optometry perform in 2011?

correct reportsOptometrists submitted 1,958,366 codes in 2011 (an increase of 29.5 percent over 2010) with a success rate of 85.64 percent (improving by 4.49 percent over 2010). The leading error again was incorrect diagnosis codes paired with PQRS measures, accounting for 12.93 percent of the errors. The two other leading errors were incorrect age matching for the measure and incorrect pairing of the CPT® codes with the PQRS measure. See the chart above for a comparison between 2010 and 2011 reporting periods. The payments for 2011 PQRS were sent in the third quarter of 2012.

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 v 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 (99201-99205, 99212-99215) or a general ophthalmologic visit code (92002-92014). The evaluation and management codes for nursing home, rest home and others are also included.

Please see the box for a complete listing. 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. As well, the patient needs to be 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 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 when 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

One of these exceptions 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 that the provider discussed the pros and cons of Age-Related Eye Disease Study (AREDS) formulation of antioxidant supplements and made proper recommendations for individual and documented discussion per the AREDS report.

For more information, see www.ExcelOD.com/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:

Glaucoma Measures2There 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. As well, the patient needs to be 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

Please note codes 365.70-365.74 were deleted from this measure for 2013.

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 IOP is reduced 15 percent or more from pre-intervention levels. QDC 3285F is used when IOP is NOT reduced 15 percent from pre-intervention levels and 0517F is added to indicate that a plan of care to get IOP reduced is in place.

The exceptions would be as follows:

3284F: 8P IOP not documented, no reason given
3285F: No exceptions because you 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 of 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. See glaucoma summary chart.


Diabetes chartThree different measures are in place for a patient with diabetes, either insulin dependent or non-insulin dependent that include measure #18, #19 and #117. See the summary for all the combinations possible.
Measure #18 and #19, using the QDC 2021F, 5010F and G8397 or G8398, are 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 never used when there is no diabetic macular edema or diabetic retinopathy. The patient must be 18 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

Diabetic macular edema

Please note 362.07-Diabetic macular edema is not one of the listed codes. The proper coding for macular edema is to report the systemic diabetic diagnosis then the proper diabetic retinopathy diagnosis and finally the diabetic macular edema diagnosis.

Only link this measure to the applicable diabetic retinopathy codes. Do not link 2021F to the systemic diabetic diagnosis or to the macular edema diagnosis.

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. 5010F indicates the provider has communicated the presence or absence of macular edema and the level of diabetic retinopathy to the physician responsible for the diabetic care. Again, the same list of diabetic retinopathy diagnoses listed for measure #18 applies to this measure. Again the patient age range is anyone 18 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 was not performed.

There are no exceptions for G8397 and G8398, but the exceptions for 5010F are:

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

Dilated diabetic exam

Measure #117 uses one of four QDCs to indicate a Dilated Diabetic Examination was performed. This measure is only used for patients 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,

The bolded diagnoses are the more common ones used by eye care providers. Re-member to link the QDC to only one diagnosis code.

The provider would 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 by an optometrist or ophthalmologist. 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).

Imaging codes

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 the diagnosis from seven standard field stereoscopic photos results and were documented and reviewed. Because most optometrists perform dilated diabetic examinations, 2022F would be the most common QDC used to report this measure.

Disease first

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 of age 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 the QDC of 2022F coded to indicate a dilated eye examination was performed (assuming that 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. However, the age for these measures is 18 and older.

Please note it is best practice for an eye care provider to communicate with all physicians caring for patients with diabetes, but PQRS only addresses this report when diabetic retinopathy and/or macular edema are found.

And 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 the penalties that will come in the future if a provider does not participate.

Providers should use the summary sheet developed by the AOA when seeing patients and coding the examinations to make the process easier (www.aoa.org/x17508.xml).

Additional information on the PQRS program can be found at www.excelod.com.

Happy Coding…


  1. This was by far the most understandable PQRS document I have seen in years. Thank you Rebecca.

  2. Excellent article. This is especially important with ICD-10 looming in 2014. It is best to implement PQRS now before learning the new coding system next year. Implementation for ICD-10 is Oct 1 2014. That will change the PQRS linked codes. So ICD-10 affects everything,

    Jeffrey Restuccio
    coding consultant for Eyecare

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