ODs can easily avoid PQRS pay penalties with AMD codes

September 12, 2013

Optometrists can still avoid having Medicare reimbursements docked 0.5 percent in 2015 under the Physician Quality Reporting System (PQRS) if they see a Medicare patient with diabetes, open-angle glaucoma, or age-related macular degeneration (AMD) by the end of the year. All that is necessary is “a good-faith effort” to provide quality patient care by taking the measures encouraged under the program, such as discussing the benefits of the Age-Related Eye Disease Study (AREDS) formulation of antioxidant supplements or providing dilated macular examinations when patients present with AMD.

“With Medicare planning to increase its quality reporting requirements over coming years, practitioners have reason to make a real effort to use PQRS codes on a regular basis,” notes Rebecca Wartman, O.D., of the AOA Third Party Executive Committee. “By doing so now, practitioners could not only avoid the coming PQRS payment penalty in 2015 but quite possibly still earn a PQRS bonus this year.”

AOA polls consistently show optometrists are already taking the steps encouraged under the PQRS to ensure high quality of care – such as providing dilated eye examinations and discussing the AREDS formula with AMD patients – so all most practitioners need to do is properly report those services to Medicare using the standard Medicare 1500 claim form along with the appropriate quality reporting code.

Medicare considers a good-faith effort to mean as little as providing PQRS quality-of-care measures to a single appropriate patient over the course of a year, so all practitioners need to do is use the PQRS codes once – on one claim form for one patient – during 2013.

This month, AOA News is focusing on the reporting of AMD quality measures through the PQRS. Features on glaucoma and diabetic retinopathy quality measures will follow in the coming months.

Two PQRS measures relate to the diagnosis of AMD:

  • Measure 14 – Age-Related Macular Degeneration: Dilated Macular Examination
  • Measure 140 – Age-Related Macular Degeneration: Counseling on Antioxidant Supplement

Practitioners may use one or both measures with any of the following three AMD diagnoses codes:

  • 362.50 – Macular degeneration NOS
  • 362.51 – Macular degeneration, non-exudative
  • 362.52 – Macular degeneration, exudative

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

The provider must dilate and record findings once per a 12-month period or once per a reporting period.

However, the quality data code QDC must be used on every claim submitted for the AMD diagnosis even when the dilated macular examination was performed during a previous patient visit.

For cases in which the practitioner could not provide a dilated examination, the PQRS provides exceptions that can be noted on claims with the following modifiers:

1P: Medical reason for no dilated macular view

2P: Patient’s reason for no dilated macular view

8P: Other reason for no dilated macula view.

However, practitioners should use such exceptions, particularly 8P, judiciously.

Measure 140, reported on claims using QDC 4177F, indicates the provider discussed the pros and cons of AREDS formulation of antioxidant supplements and made proper recommendations for the individual and documented the discussion per the AREDS report.

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 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.

The AMD quality measures are applicable only to patients age 50 or older.

For additional information, including the AOA Summary Chart of PQRS coding, visit www.excelod.com/pqrs.

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