• Still Time to Avoid the Penalty — Get Cracking on PQRS and E-Prescribing

    In 2007, CMS established the Physician Quality Reporting System (PQRS), a pay-for-reporting program that includes claims- and registry-based reporting of data on individual quality measures or on a cataract group measure. PQRS was the first of three incentive programs that also include e-prescribing and meaningful use. Since PQRS’ inception, physicians have had the opportunity to report quality measures and, if they submit correctly, receive 0.5 to 2 percent payment incentives of all their allowable amounts (less durable medical equipment and any injectable drug) for all Medicare Part B, Medicare as a Secondary Payer and Railroad Medicare payments. With help from the Academy, ophthalmology has been successful in developing more than 15 ophthalmic-specific individual quality measures, plus the cataract group measure. 

    The second incentive program, e-prescribing, began in 2009. Those physicians who adopted e-prescribing for their practice received a 2 percent incentive payment in addition to the PQRS payment.

    While the early phases of these programs included only positive payment adjustments for participation (i.e., bonuses), CMS will soon begin phasing in negative adjustments — penalties — for those who don’t participate or don’t report successfully. Though these cuts won’t take effect until 2015, they’re based on what you do this year. For example, those ophthalmologists who don’t successfully report PQRS in 2013, or at least attempt to report, will be subject to a 1.5 percent payment adjustment in 2015.

    Which best describes your participation in PQRS in 2013?

    1. I’m reporting a minimum of three measures through my office (claims-based reporting).
    2. I’m planning to report a minimum of three measures through a qualified CMS registry.
    3. I’m planning to report 20 cataract surgical cases through a qualified CMS registry.
    4. I’m reporting three measures correctly 80 percent of the time via CMS-approved electronic health records.

    PQRS participation at a glance

    For anyone who is thinking “none of the above,” we strongly encourage you to reconsider and select one of these four options available to ophthalmologists. Recent data from CMS reveals that only 46.5 percent of ophthalmologists participated in PQRS in 2011 (data from 2012 won’t be available until this time next year). The 7,011 ophthalmologists who reported successfully took home a total of $26 million in incentive payments. The incentive payment was based on 1 percent of all Medicare Part B, Medicare as a Secondary Payer and Railroad Medicare allowables, less durable medical equipment and any injectable drug.

    Most ophthalmologists continue to participate in claims-based reporting, and the good news is that this participation is growing. In 2010, only 58 percent of ophthalmologists reporting claims achieved the bonus; however, in 2011, 76 percent achieved the bonus. And for those ophthalmologists who decided on registry-based reporting, success rates remained high at around 90 percent for both years.

    Ophthalmology had one measure, Measure 19: Diabetic Retinopathy — Communication with the Physician Managing Ongoing Diabetes Care, that was flagged for a significant amount of incorrect reporting. For this measure, 26 percent of reported instances did not include an appropriate diagnosis code. The only diagnosis codes associated with this measure are:

    • 362.01 Background diabetic retinopathy
    • 362.02 Proliferative diabetic retinopathy 
    • 362.03 Nonproliferative diabetic retinopathy (NOS)
    • 362.04 Mild nonproliferative diabetic retinopathy
    • 362.05 Moderate nonproliferative diabetic retinopathy
    • 362.06 Severe nonproliferative diabetic retinopathy

    E-prescribing participation at a glance

    Ophthalmology doubled its participation in the e-prescribing incentive program in 2011. In 2010, just 33 percent of ophthalmologists participated, while in 2011, 60 percent of ophthalmologists participated. As a result, ophthalmology is in the top four of all specialties for participation.

    The average ophthalmology incentive was $4,448.30, and ophthalmologists took home a total of $35 million in e-prescribing incentive payments.

    Unfortunately, 3.8 percent of ophthalmologists were subject to 2012 e-prescribing payment adjustments.

    For more information about e-prescribing and PQRS, including reporting options by specialty, visit www.aao.org/pqrs, or email your questions to pqrs@aao.org. And remember, physicians who do not at least attempt to report in 2013 will be subject to a 1.5 percent payment adjustment in 2015.

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    About the author: Sue Vicchrilli, COT, OCS, is the Academy’s coding executive and the author of EyeNet’s “Savvy Coder” column and AAOE's Coding Bulletin, Ophthalmic Coding Coach and the Ophthalmic Coding series. Kelsey A. Kurth, MPP, is the Academy’s manager of quality and payment policy.