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Optometrists can avoid PQRS pay penalties by reporting quality measures for diabetes

November 14, 2013
Optometrists who participate in the Medicare Physician Quality Reporting System (PQRS) during 2013 will avoid payment penalties in 2015. Fortunately, participating is easier than many practitioners think. See what Rebecca Wartman, O.D., of the AOA Federal Relations Committee, has to say at http://bit.ly/14LrPw4.

Optometrists who participate in the Medicare Physician Quality Reporting System (PQRS) during 2013 will avoid payment penalties in 2015. Fortunately, participating is easier than many practitioners think. See what Rebecca Wartman, O.D., of the AOA Federal Relations Committee, has to say at http://bit.ly/14LrPw4.

Any optometrist who sees a Medicare patient with diabetes during the remainder of 2013 can still avoid having Medicare reimbursements docked 0.5 percent in 2015 under the Physician Quality Reporting System (PQRS). All that is necessary is “a good-faith effort” to provide quality patient care by taking the measures encouraged under the program, such as dilated eye examinations for patients with diabetes.

Medicare has indicated a good-faith effort can 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 for one patient – during 2013 to avoid the PQRS payment penalty in 2015.

“Although, 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,” said Rebecca Wartman, O.D., AOA Third Party Center Executive Committee member. “By doing so, practitioners could not only avoid the coming PQRS payment penalty but quite possible still earn a PQRS bonus this year.”

PQRS and diabetes

When optometrists see a patient with diabetes, they can meet either PQRS measures 18, 19 or 117 (see box below), depending on exactly how they elect to handle the patient and the status of the patient’s diabetes and related eye conditions.

Basically, the PQRS program encourages eye care practitioners to provide any patient, age 18 to 75, who has diabetes, insulin or non-insulin dependent, with a dilated macular or fundus examination, report the results to the patient’s care provider, – or explain why such an examination was not provided.

An optometrist can report compliance with measure 18 or 19 when providing a patient age 18 or older with diabetes a dilated eye exam and diabetic retinopathy (DR) is found. The optometrist performs the examination and then documents the presence or absence of macular edema and the level of diabetic retinopathy using the diagnosis codes.

Measures #18 and #19, using QDC 2021F, QDC 5010F and G8397 or G8398, are used with diabetes only 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
  • 362.03 Severe Nonproliferative Diabetic Retinopathy

It is important to note that diabetic macular edema (362.07) is not one of the listed codes. Take these steps for properly coding for macular edema:

  • Report the systemic diabetes diagnosis (250.00),
  • Report the proper diabetic retinopathy diagnosis
  • Report the diabetic macular edema diagnosis.

Only link measures 18 and 19 to the applicable diabetic retinopathy codes.

Do not link the 2021F to the systemic diabetic diagnosis or to the macular edema diagnosis.

The exceptions for 2021F are as follows:

  • 1P – Medical reason for 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. Code 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 for measure 18 applies to 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. However, there are two exceptions for 5010F:

  • 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 used only 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, 648.01-648.04.

Diagnoses 250.00-250.03, 250.50-250.53, 362.01-362.07 are the ones more commonly used by eye care providers.

Remember to link the QDC to only one diagnosis code.

The provider would use one of the following QDCs to report this measure:

  • QDC 2022F – dilated eye exam performed on a diabetic patient by an optometrist or ophthalmologist
  • QDC 3072F – used when the patient is at low risk for diabetic retinopathy, indicating the 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 measure 117, but are not commonly used by eye care providers:

  • QDC 2024F is used for reporting seven standard field stereoscopic photos with interpretation by an ophthalmologist or optometrist were documented and reviewed.
  • QDC 2026F is used to indicate eye imaging was validated to match the diagnosis from seven standard field stereoscopic photos documented and reviewed.

However, because most optometrists perform dilated diabetic examinations, 2022F would be more commonly used than 2024F and 2026F.

For additional information, visit http://bit.ly/GXJoE8.

PQRS eye care measures for patients with diabetes

  • Measure 18 – Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level of Severity of Retinopathy: Percentage of patients age 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed that included documentation of the level of severity of retinopathy and the presence or absence of macular edema during one or more office visits within 12 months.
  • Measure 19 – Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care: Percentage of patients age 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed with documented communication to the physician who manages the ongoing care of the patient with diabetes mellitus regarding the findings of the macular or fundus exam at least once within 12 months.
  • Measure 117 – Diabetes Mellitus: Dilated Eye Exam: Percentage of patients age 18 to 75 with a diagnosis of diabetes mellitus who had a dilated eye exam.

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