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Savvy Coder: Coding & Reimbursement
How to Implement the New CMS Pay-for-Performance Program
By Sue Vicchrilli, COT, OCS, Academy Coding Executive

The CMS is offering a 1.5 percent bonus to encourage participation in its Physician Quality Reporting Initiative. This new program will track performance over a six-month period, and the clock starts ticking on July 1. At time of press, the documentation requirements were expected to be as given below. You can review the final rules at


How PQRI Works

The PQRI includes 74 measures. Eight of these are ophthalmic-specific (see measures #12 to #19 below). From these, choose at least three that apply to you. To get the bonus, you must perform each of three measures at least 80 percent of the time between July 1 and Dec. 31. For each measure, the CMS has published a list of associated diagnosis codes and a CPT Category II code that you can use to document performance.


Eight Ophthalmic Measures

#12 Optic nerve evaluation for primary open-angle glaucoma patients. CPT II code: 2027F.* Diagnosis codes: 365.01, 365.10, 365.11, 365.12 or 365.15.

#13 Antioxidant supplement prescribed/recommended for age-related macular degeneration patients. CPT II code: 4007F.* Diagnosis codes: 362.50, 362.51 or 362.52.

#14 Dilated macular exam for AMD patients. CPT II code: 2019F.* Diagnosis codes: See measure #13.

#15 Assessment of visual function status for cataract patients. CPT II code: 1055F.* Diagnosis codes: 366.00, 366.01, 366.02, 366.03, 366.04, 366.09, 366.10, 366.11, 366.12, 366.13, 366.14, 366.15, 366.16, 366.17, 366.19, 366.20, 366.22, 366.34, 366.41, 366.42, 366.43, 366.45 or 366.46.

#16 Documentation of presurgical axial length, corneal power measurement and method of IOL calculation for cataract patients. CPT II code 3073F*, in addition to CPT I code 66982, 66983 or 66984.

#17 Presurgical dilated fundus evaluation for cataract patients. CPT II code: 2020F*, in addition to CPT I code 66840, 66850, 66852, 66920, 66930, 66940, 66982, 66983 or 66984.

#18 Documentation of presence or absence of macular edema and level of severity of retinopathy for diabetic retinopathy patients. CPT II code: 2021F.* Diagnosis codes: 362.01, 362.02, 362.03, 362.04, 362.05 or 362.06.

#19 Communication with the physician managing ongoing diabetes care for diabetic retinopathy patients. CPT II code: 5010F and 2021F.* Diagnosis codes: See measure #18.


* Also use the appropriate level of exam.



Nonperformance Modifiers

What if the patient refuses the service? Will that impact your performance rating? When nonperformance is due to reasons beyond your control, you may be able to append one of the following modifiers to the CPT II code.

–1P Performance measure exclusion modifier due to medical reasons. Not indicated or contraindicated, such as an allergic history. (This can be used with measures #12, #13, #14, #15, #16, #18 and #19.)

–2P Performance measure exclusion modifier due to patient reasons. Patient declined for economic, social or religious reasons. (This can be used with measures #14, #17, #18 and #19.)

–8P Performance measure exclusion modifier, reason not specified. (This can be used with measures #12, #13, #14, #15, #16, #17, #18 and #19.)