• Savvy Coder

    PQRS—What You Must Do Now to Avoid a Financial Penalty in 2015

    By Sue Vicchrilli, COT, OCS, Academy Coding Executive and Kelsey Lang, MPP, Academy Manager, Quality and Payment Policy

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    If you have yet to report 2013 data for PQRS, you should consider the financial consequences of the following three scenarios.

    1. Report all the required data successfully. Options still remain if you want to qualify for the 0.5 percent Medicare bonus. All details can be found at www.aao.org/pqrs.

    2. Do nothing. You will suffer a 1.5 percent payment adjustment in 2015. This penalty, like the bonus, is based on all your allowable amounts less durable medical equipment and any injectable drug for Medicare Part B, Medicare as a secondary payer, and Railroad Medicare payments.

    3. Report a minimal amount of data. Although this won’t be enough to qualify for the bonus, you can avoid the penalty if you follow the five simple steps below. But you must act now.

    How to Avoid the Penalty

    To avoid the 1.5 percent payment adjustment in 2015, you must report one measure. You only need to report it one time, but you should verify that it is received by CMS. Claim submission must be completed by Dec. 31, 2013.

    Step 1. Pick one of these measures:

    • 12—POAG: Optic Nerve Evaluation
    • 14—AMD: Dilated Macular Examination
    • 18—Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level of Severity of Retinopathy
    • 19—Diabetic Retinopathy: Communication With the Physician Managing Ongoing Diabetes Care
    • 117—Diabetes Mellitus: Dilated Eye Exam in Diabetic Patient
    • 130—Documentation of Current Medications in the Medical Record
    • 140—AMD: Counseling on Antioxidant Supplement
    • 141—POAG: Reduction of IOP by 15 Percent or Documentation of a Plan of Care
    • 226—Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention

    To see the Category II CPT codes that pertain to each of these nine measures, visit www.aao.org/pqrs.

    Step 2. Submit the Category II CPT code on the CMS 1500 form along with the appropriate level of E&M or Eye code that matches the documentation for the exam the same day.

    Step 3. For seven of the measures—12, 14, 18, 19, 117, 140, and 141—CMS requires you to link a qualifying diagnosis to the measure. Please note: Although no diagnosis codes are listed for measures 130 and 226, the system you use to report PQRS may automatically suspend the code if there is no linked diagnosis even if CMS would have accepted it. Avoid this potential problem by linking one of the diagnoses from the exam.

    Step 4. Put a charge of one cent in the unit field. While CMS may accept a code without an associated charge, your system might suspend the code without a charge. Hence, charge one cent and adjust it off when the claim is paid. Remember, if the exam is denied, the measure will be denied, too.

    Step 5. Confirm the measure has been received by CMS. Either N365 or C096 should appear on the claim remittance advice RA when CMS makes the payment. This confirms the submission was successful.


    Multimedia Extra

    In the slideshow above, Sue Vicchrilli, COT, OCS, explains how to avoid the PQRS penalty. (For full-screen view, click bottom-right corner of the slide.)