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February 2012

Savvy Coder: Coding & Reimbursement
What’s New With PQRS and E-Prescribing
By Kelsey Kurth, Academy Health Policy Manager, Kim Ross, OCS, CPC, Academy Coding Specialist, and Sue Vicchrilli, COT, OCS, Academy Coding Executive
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If your practice is participating in the e-prescribing and Physician Quality Reporting System (PQRS) incentive programs, here are some highlights of what’s new this year. If you haven’t yet taken part in these programs, you can find out how to get started at and

PQRS: New Measures Group

Eye M.D.s can satisfy their reporting requirements either by reporting on individual measures or by reporting on one measures group. Last year there were 14 measures groups, but none of them applied to ophthalmology. This year, CMS has added eight new groups, including one that focuses on cataract.

Cataracts measures group. This group is intended for surgical cases in which the surgeon provides pre- and postop care. It consists of the following four measures, two of which—303 and 304—are new this year:

  • Measure 191: 20/40 or better visual acuity within 90 days following cataract surgery
  • Measure 192: Complications within 30 days following cataract surgery requiring additional surgical procedures
  • Measure 303: Improvement in patient’s visual function within 90 days following cataract surgery
  • Measure 304: Patient satisfaction within 90 days following cataract surgery

Reporting tips. You can successfully report on the cataracts measures group by reporting the four measures for a minimum of 30 cases. These don’t have to be consecutive patients.

  • Cataract measures can only be reported by submitting your data to a qualified registry, which then forwards it to CMS—not through office-based claims reporting, which involves including data in your Medicare claims forms.
  • The reporting period for the initial cataract surgery is Jan. 1 to Sept. 30. Registries will need the last three months to follow up on surgical outcomes.
  • The registry, not the physician’s office, will survey patients regarding their visual function/satisfaction following surgery.
  • When reporting on the cataracts measures group, you’ll need to successfully report on 30 patients. If you instead opt to report any of the cataract measures individually, you will need to obtain 80 percent reporting success. The advantage of the measures group is the lower reporting threshold.
  • The incentive payment is 0.5 percent of all your Medicare Part B, Medicare as a secondary payer and Railroad Medicare allowables, less durable medical equipment and injected drugs.

Which patients can you include in your 30 cases? Patients with the following surgical codes can be included:

  • 66840 Removal of lens material; aspiration technique, one or more stages
  • 66850 Removal of lens material; phacofragmentation technique (mechanical or ultrasonic) (e.g., phacoemulsification), with aspiration
  • 66852 Removal of lens material; pars plana approach, with or without vitrectomy
  • 66920 Removal of lens material; intracapsular
  • 66930 Removal of lens material; intracapsular, for dislocated lens
  • 66940 Removal of lens material; extracapsular (other than 66840, 66850, 66852)
  • 66983 Intracapsular cataract extraction with insertion of intraocular lens prosthesis (one stage procedure)
  • 66984 Extracapsular cataract removal with insertion of intraocular lens prosthesis (one stage procedure), manual or mechanical technique (e.g., irrigation and aspiration or phacoemulsification)

Note that 66982, the code for complex cataract extraction, is not included.


Other PQRS News

All the PQRS measures from 2011 were retained for 2012.

Biopsy follow-up. This year, there is a new measure for biopsy follow-up.

  • Measure 265: Percentage of patients whose biopsy results have been reviewed and communicated to the primary care/referring physician and patient by the performing physician

You can only report this measure via a registry, and you would report it once per reporting period for patients who are seen for an office visit and have a biopsy performed. If you are reporting individual measures (rather than a measures group) via a registry, then the reporting period is 12 months (Jan. 1 to Dec. 31).

Reporting via claims? There is only one reporting period—Jan. 1, 2012, through Dec. 31, 2012.

For more PQRS information, visit, where you can review lists of PQRS measures organized by subspecialty, as well as learn about Outcome Science’s web-based registry.


E-Prescribing Update

Unfortunately, some physicians will receive payment adjustments in 2012 because they did not e-prescribe in 2011. However, there is still time to avoid the penalty in 2013 by e-prescribing or by requesting the new exemption for physicians who write fewer than 100 prescriptions over six months.

Do you plan to e-prescribe? HCPCS code G8553 is the correct code to use for 2012 and for all future years of the e-prescribing program.

To avoid a 1.5 percent penalty in 2013, you will need to e-prescribe a minimum of 10 times from Jan. 1, 2012, through June 30, 2012. The e-prescriptions can be associated with any Part B service, and you will only be able to report via claims.

To earn the 1 percent 2012 incentive payment and avoid a 2 percent penalty withholding in 2014, you will need to e-prescribe 25 times from Jan. 1, 2012, to Dec. 31, 2012. The e-prescriptions must be associated with an office visit, and you can report either by claims or by registry.

Do you qualify for an automatic exception? You may be automatically excluded from the penalty if you are:

  • an eligible physician for whom office visits and other services listed in the CMS e-prescribing measure specifications represent less than 10 percent of your allowed Medicare charges in the first six months of 2012; or
  • an eligible physician who has fewer than 100 claims for patient services containing visit and service codes that fall within the e-prescribing measure specifications for dates of service between Jan. 1, 2012, and June 30, 2012.

Can you request an exemption from CMS? You may request to be excluded from the penalty if you are:

  • a physician who writes fewer than 100 prescriptions between Jan. 1, 2012, and June 30, 2012.
  • a physician who is unable to e-prescribe due to local, state or federal law or regulation.
  • a physician who practices in a rural area without high-speed Internet access or with insufficient pharmacies to e-prescribe.


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