It Takes Team Work To Be Successful

Transcription

1 Conquering Coding and ICD-1, Avoiding PQRS, and VBM Penalties It Takes Team Work To Be Successful

2 Financial Disclosure Ronald L. Fellman, MD Cynthia Mattox, MD, FACS Sue Vicchrilli, COT, OCS No financial interest or relationship to disclose relative to this course content.

3 Topics #1 Rule of Coding 215 Update ICD-1-CM Review Code this Superbill PQRS and Value-Based Modifier Audits Good News!

4 First Things First Before physicians greet the patient or obtain the chief complaint Identify the payer! There is very little standardization among third-party payers. Medicare Part B Commercial Insurance Medicaid Medicare Advantage Plans Affordable Care Act ACA 1. Group/Employer or Individual plans 2. Check Eligibility 3. Prior Authorization or referral requirements 4. No pre-existing, but may have waiting periods 5. Allowable 6. Global periods

5 AGS 215 Updates

6 New HCPCS Modifiers New HCPCS modifiers to replace modifier -59 Distinct procedural service effective January 1, 215 May be CMS only Primary reason to use modifier -59 is to break CCI edit If no CCI edit, generally there is no need to append modifier -59 or any -X modifier

7 New HCPCS Modifiers Instructions state that modifier -59 should not be used when a more descriptive modifier is available. The X modifiers are more selective versions of modifier -59 so it would be incorrect to include both modifiers on the same line.

8 New HCPCS Modifiers -XE -XS Separate Encounter, A service that is distinct because it occurred during a separate encounter Separate Structure, A service that is distinct because it was performed on a separate organ/structure -XP -XU Separate Practitioner, A service that is distinct because it was performed by a different practitioner Unusual Non-Overlapping Service, the use of a service that is distinct because it does not overlap usual components of the main service

9 Correct Coding Initiative CCI Only published example: Column 1 Code / Column 2 code /6722 CPT Code 6721 Destruction of localized lesion of retina (eg, macular edema, tumors), 1 or more sessions; photocoagulation ($514) CPT Code 6722 Destruction of localized lesion of choroid (eg, choroidal neovascularization); photocoagulation (eg, laser), 1 or more sessions ($52) CPT code 6722 should not be reported and modifier -59 should not be used if both procedures are performed during the same operative session because the retina and choroid are contiguous structures of the same organ.

10 Correct Coding Initiative CCI CPT code Insertion on anterior segment aqueous drainage device... external approach G463, 191T, 253T, 1211, 1213, 1214, 1215, 1216, 1217, 1218, 1251, 1252, 1253, 1254, 1255, 1256, 1257, 13151, 13152, 13153, 658, 6581, 65815, 662, 663, 675, 67515, 9212, 9214, 9218, 9219, 99212, 99213, 99214, 99215, 99217, 99218, 99219, 9922, 99221, 99222, 99223, 99231, 99232, 92333, 99234, 99235, 99236, 99238, 99239, 99241, 99242, 99243, 99244, 99245, 99251, 99252, 99253, 99254, 99255, 99291, 99292, 9934, 9935, 9936, 9937, 9938, 9939, 9931, 99315, 99316, 99334, 99335, 99336, 99337, 99347, 99348, 99349, 9935, 99374, 99375, 99377, 99378

11 Correct Coding Initiative CCI CPT code Scanning computerized ophthalmic diagnostic imaging 9225 Mutually Exclusive: 92134, 92227

12 CCI Edits Column 1 and Column 2 Edits Column 1 Column 2 Effective Date =not allowed 1=allowed (Jan/1/22)

13 CPT Code Update Anterior Sclera section of Eye and Ocular Adnexa Fistulization of sclera for glaucoma; iridencleisis or iridotasis has been deleted

14 Glaucoma Codes CMS targeted the shunt codes in 213 as potentially misvalued Identified that the patch graft code was being used along with 6618 more than 7% of the time Which results in requiring review of the family of CPT codes.

15 CPT Code Update New code: Aqueous shunt to extraocular equatorial plate reservoir, external approach; without graft $1,1

16 CPT Code Update 6618 Aqueous shunt to extraocular reservoir (eg, Molteno, Schocket, Denver- Krupin) with graft 214 $1, $1,159 When performed with the graft, the surveys showed less physician time.

17 CPT Code Update New code: Revision of aqueous shunt to extraocular equatorial plate reservoir; without graft $82

18 CPT Code Update Revision of aqueous shunt to extraocular reservoir with graft 214 $ $861

19 CPT Code Update Do not report 6618 Aqueous shunt with graft or Revision with graft In conjunction with Scleral reinforcement (separate procedure); with graft What about private payers?

20 CPT Code Update Special Testing Services Corneal hysteresis determination, by air impulse stimulation, unilateral or bilateral, with interpretation and report Replaces Category III code 181T $16 historically May not be recognized by commercial payers initially

21 Category III Codes Category III codes are designed to report and track new services, infrequent services or services employing emerging technology.

22 Category III Codes Unless or until a payer develops a coverage/payment policy, patients are responsible for the fee.

23 Category III Codes Always best to have a Medicare Part B patient sign an ABN and submit the claim appended with modifier -GA indicating that you have an ABN on file in the office.

24 Category III Codes 356T Insertion of drug-eluting implant (including punctal dilation and implant removal when performed) into lacrimal canaliculus, each Sunset January 22 For IOP measurement

25 Category III Codes CCI Edits for 356T: Retrobulbar injection 675 Lacrimal system 6844, 6853, 687, 6877, 6881, 6881, Established eye exam codes 9212, 9214, 9218, 9219, and Established patient E/M codes

26 Category III Codes 191T Insertion of anterior segment aqueous drainage device, without extraocular reservoir, internal approach, into the trabecular meshwork; initial insertion Sunset January 219 $772

27 Category III Codes + 376T each additional device insertion (List separately in addition to code for primary procedure) Sunset January 219 No allowable established yet Billable to patient?

28 Category III Codes 253T Insertion of anterior segment aqueous drainage device, without extraocular reservoir, internal approach, into the suprachoridal space Sunset January 219 $849 External approach CPT code $1,46

29 PECOS All physicians who enrolled with Medicare prior to March 25, 211, are required to revalidate their Medicare enrollment.

30 PECOS Physicians have 6 days from the date of the revalidation notice to submit their complete enrollment information. You will receive revalidation letter through the mail when it is your turn.

31 Do not delay PECOS Delaying = no payments

32 Coding Competency You hire a new physician (any licensed person) in your practice. Best to check with the OIG first and at regular intervals

33 Future Fee Schedule Issues Review of Work Values CMS proposes to review several ophthalmic services as potentially misvalued by CMS. Targeting codes with more than $1 million in annual allowed charges Please complete any survey received!

34 Fee Schedule Ophthalmology codes that meet these criteria include: YAG laser Trabeculoplasty Panretinal photocoagulation Punctal plug closure Biometry 9225 Fundus photography

35 Questions

36 CODEquest ICD-1-CM

37 ICD-1-CM Target date is October 1, 215 All systems seem to be go! Testing went extremely well Will not accept another delay in lieu of not fixing the SGR.

38 Third Party Liability Although they may choose to do so, the following are not required to transition to ICD-1: Workers Compensation Auto insurance Home owners insurance, and/or Business owner liability

39 ICD-1-CM Practices do not need electronic health records (EHR) to effectively report I-1. Coders are trained to use the book Alphabetical Index Tabular List

40 ICD-1-CM Ophthalmology is the only medical specialty to have their own specific ICD-1-CM book. Designed for ophthalmology by an ophthalmologist.

41 ICD-1-CM Don t waste time learning the tricks of the trade. Instead, learn the trade.

42 Chapters Chapter Topic 1 Certain Infectious and Parasitic Diseases ICD-1 Codes A-B99 2 Neoplasms C-D49 3 Diseases of the blood and blood D5-D89 forming organs and certain disorders involving the immune mechanism 4 Endocrine, Nutritional, and Metabolic E-E89 Diseases 6 Diseases of the Nervous System G-G99 7 Diseases of the Eye and Adnexa* H-H59 See slide with details

43 Chapters Chapter Topic 8 Diseases of the ear and mastoid process ICD-1 Codes H6-H95 9 Diseases of the circulatory system I-I99 1 Diseases of the respiratory system J-J99 11 Diseases of the digestive system K-K94 12 Diseases of the skin and subcutaneous tissue 13 Diseases of the musculoskeletal system and connective tissue L-L99 M-M99

44 Chapters Chapter Topic ICD-1 Codes 14 Diseases of the genitourinary system N-N99 15 Pregnancy, childbirth and the O-O99 puerperium 16 Certain conditions originating in the P-P96 perinatal period 17 Congenital malformations, Q-Q99 deformations and chromosomal abnormalities

45 Chapters Chapter Topic 18 Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified 19 Injury, Poisoning, and Certain other Consequences of External Causes 2 External Causes of Morbidity (Current E codes) 21 Factors Influencing Health Status and Contact with Health Services (Current V codes) ICD-1 Codes R-R99 S-T88 V-Y99 Z-Z99

46 V Codes = Z Codes Pseudophakia Z96.1 No laterality Cataract extraction status, right eye Z98.41 Cataract extraction status, left eye Z98.42 Plus status Pseudophakia Aphakia Z96.1 No laterality, or H27.1, 2, 3 Corneal transplant status Z94.7 No laterality

47 Chapter 7 Diseases of the Eye and Adnexa H-H5 H1-H11 H15-H22 H25-H28 H3-H36 H4-H42 H43-H44 H46-H47 H49-H52 Disorders of eyelid, lacrimal system and orbit Disorders of conjunctiva Disorders of sclera, cornea, iris and ciliary body Disorders of lens Disorders of choroid and retina Glaucoma Disorders of vitreous body and globe Disorders of optic nerve and visual pathways Disorders of ocular muscles, binocular movement, accommodation and refraction

48 Chapter 7 Diseases of the Eye and Adnexa H53-H54 Visual disturbances and blindness H55-H57 Other disorders of eye and adnexa H59 Intraoperative and postprocedural complications and disorders of eye and adnexa, not elsewhere classified

49 ICD-1-CM Nuances

50 Terminology indicates zero as in 8, 9, 1 vs. L, M, N, O, P The or O is very important to consider during data entry.

51 Terminology X as a placeholder or for future expansion of the code. H21.1X- Other vascular disorders of iris and ciliary body H21.1X1 Other vascular disorders of iris and ciliary body, right eye H21.1X2, left eye H21.1X3, both eyes

52 Terminology In the alphabetical index A (-)means to look for additional codes in the family. Glaucoma H4.9 Absolute H Acute (attack) (crisis) H4.21- Anatomic narrow angles H4.3-

53 Terminology Visual field defects H53.4 Scotoma involving central area H Scotoma of blind spot area H Homonymous bilateral field defects H (right and left side only) Heteronymous bilateral field defects H53.47 (no dash one code) Sector or arcuate defects H Generalized contraction of VF H Other localized VF defects H53.45-

54 Terminology And means and/or H26.- Infantile and juvenile cataract H26.3- Infantile and juvenile nuclear cataract H26.31, right eye H26.32, left eye H26.33, both eyes

55 Terminology Excludes1 Note Indicates mutually exclusive codes such as two conditions that cannot be reported together.

56 Terminology H4 Glaucoma Excludes1: Absolute glaucoma H Dash Congenital glaucoma Q15. Traumatic glaucoma due to birth injury P15.3

57 Terminology H Cystoid macular degeneration Excludes1: cystoid macular edema following cataract surgery (H59.3-)

58 Terminology Excludes2 Note Indicates a patient may have both conditions at the same time.

59 Terminology H25 Age-related cataract Senile cataract Excludes2: capsular glaucoma with pseudoexfoliation of lens (H4.1-)

60 Glaucoma Glaucoma coding options for ICD-1: Not all diagnoses have laterality. Not all diagnoses have staging. Code the most severe eye when staging is required.

61 Terminology Glaucoma staging codes Add the appropriate 7th final character when indicated, for: stage unspecified 1 mild stage 2 moderate stage 3 severe stage 4 indeterminate stage

62 Terminology Example: When diagnosing capsular glaucoma with pseudoexfoliation of lens, mild stage H right eye H left eye H both eyes

63 Terminology chapter header capsular w/pseudoexfoliation H mild stage right eye

64 Terminology Example: When diagnosing primary open-angle glaucoma, severe stage, right eye H4.11X3

65 Terminology chapter header - glaucoma POAG H4.11X3 severe stage placeholder Note: This code does not have laterality, so X is used as the placeholder.

66 Terminology Example: When diagnosing capsular glaucoma with pseudoexfoliation of lens, mild stage OD, Severe stage OS H right eye - mild H left eye - severe

67 Glaucoma 82 year-old female with uncontrolled pressure, has moderate stage POAG (H4.11) and undergoes a trabeculectomy in her left eye. 1. H4.11X2 as there is no laterality 2. H as there is laterality

68 Terminology Trauma or injury diagnosis codes (Begin with S or T) often require identification of the type of visit. A = initial encounter D = subsequent encounter S = sequela (Condition resulting from a disease, injury, or other trauma)

69 Terminology A, D, and S are 7th digit codes and as such generally require the use of X as a placeholder in the 6th position. If diagnosing a subsequent visit for a patient with penetrating wound of orbit with or without foreign body, left eye submit S5.42XD

70 Terminology chapter header - injury penetrating wound S5.42XD placeholder subsequent encounter left eye

71 Terminology Recurrent erosion of the left eye from previous corneal abrasion. Submit H recurrent erosion, left eye S5.12XS corneal abrasion, left eye

72 ICD-1 Speak? Observe the punctuation and crossreference any notation. E8 Diabetes mellitus due to underlying condition Code first the underlying condition, such as: Congenital rubella (P35.) Cushing s syndrome (E24.-) Cystic fibrosis (E84.-) Malignant neoplasm (C C96) Malnutrition (E4 E46) Pancreatitis and other diseases of the pancreas (K85 K86.-) Use additional code to identify any insulin use (Z79.4)

73 Dissecting Codes When with/without are options for the final character of a set of codes, 1 may represent with E with macular edema 9 represents without E without macular edema

74 Dissecting Codes in the last position Unspecified eye 1 in the last position might represent Right eye 2 in the last position might represent Left eye 3 in the last position might represent Bilateral 9 in the last position Unspecified eye But not always!

75 Dissecting Codes Diagnosis affecting eyelids 1 in the last position Right upper eyelid 2 in the last position Right lower eyelid 3 in the last position Right eye, unspecified eyelid 4 in the last position Left upper eyelid 5 in the last position Left lower eyelid 6 in the last position Left eye, unspecified eyelid 9 in the last position Unspecified eye, unspecified eyelid

76 Dissecting Codes Modifiers -RT, -LT still required for CPT code, and Lid modifiers will still be required as well for CPT codes E1 Left upper E2 Left lower E3 Right upper E4 Right lower

77 Case Studies Paradigm Shift: A change from one way of thinking to another. It's a revolution, a transformation, a sort of metamorphosis. It just does not happen, but rather it is driven by agents of change.

78 Persons with Diabetes What chapter? Chapter 4: Endocrine, Nutritional and Metabolic Diseases No more NIDDM in chart note No more controlled or uncontrolled These terms will be obsolete as they do not convert to ICD-1.

79 Persons with Type 1 Diabetes

80 Persons with Type 2 Diabetes

81 Plaquenil Evaluation Patients who are on long-term medication are often referred to an ophthalmologist for evaluation. When there are no findings, code the underlying medical condition. Lupus: L93. Rheumatoid arthritis: M6.9

82 Plaquenil Evaluation Note: Not all payers recognize systemic diseases as payable diagnosis for Eye codes. Best to submit the appropriate level of E/M service in these situations.

83 Plaquenil Evaluation If there are findings: Chapter header for Other retinal disorders Toxic maculopathy Other long term (current) drug therapy H35 H H right eye H left eye H both eyes Z79.899

84 Macular Degeneration Options when cross referencing to the Tabular List for H35.3: H35.31 Nonexudative age-related macular degeneration Atrophic age-related macular degeneration H35.32 Exudative age-related macular degeneration

85 Macular Degeneration Select the correct ICD-1 code selection for wet AMD in the right eye: 1. H H H35.321

86 Additional Conquering ICD-1 Resources ICD-1-CM 214 for Ophthalmology book Conquering ICD-1-CM Workbook 9-Minutes to Conquering ICD-1-CM elearning

87 Additional Conquering ICD-1 Resources Series of EyeNet articles Savvy Coder with specialty societies To launch in March: ICD-9 to ICD-1 online

88 Additional Conquering ICD-1 Resources Website: Questions? to

89 Questions?

90 AGS 215 Code This Superbill H26.2 = $

91 Code This Superbill When to bill an E/M and when to bill an Eye code?

92 E/M vs. Eye Codes CPT code Commercial Medicare 9921 $48. $ $83. $ $121. $ $183. $ $229. $ $78. $ $119. $135.74

93 E/M vs. Eye Codes CPT code Commercial Medicare $22. $ $48. $ $81. $ $119. $ $161. $ $76. $ $115. $112.25

94 Code This Superbill #1 Patient has: Mild glaucoma in the right eye, and Severe glaucoma in the left eye CPT code SCODI is performed Do you code the most severe eye only? 1. Yes 2. No

95 Code This Superbill #2 Is needling of the bleb billable, during the global period, when performed at the slit-lamp in my office? CPT code 6625 Wound revision

96 Code This Superbill #3 In order to bill CPT code Trab with scarring from previous surgery - Does it have to be previous glaucoma surgery? What documentation is required?

97 Code This Superbill #4 Patient underwent a trab in the left eye. During the global period, the surgeon perform insertion of an aqueous shunt with scleral reinforcement. What modifier should be appended? -78 unplanned related -58 staged

98 Code This Superbill #5 We no longer append modifier -51 to any multiple procedures performed. Medicare has been appending modifier -51 to some testing services when more than one are performed on the same day. Why?

99 Code This Superbill #6 I say that injections given in the exam lane, during the global period of another surgery are part of the surgical package. But the drug can be billed. Our new coder says the injection is billable. Who is right?

100 Code This Superbill #7 Is there a difference between nursing homes and skilled nursing facilities when it comes to billing?

101 Code This Superbill #8 How should we be coding glaucoma follow-up visits?

102 Code This Superbill #9 Is laser suture lysis ever billable? Office? Facility?

103 Code This Superbill #1 CPT code Severing adhesions of anterior segment is not bundled with CPT code Cataract extraction with IOL. Why is the payer denying payment?

104 Code This Superbill #11 A Bilateral peripheral iridotomies are performed. Correct coding?

105 Code This Superbill #11 B During the global period an SLT is performed bilaterally. Correct coding?

106 Code This Superbill #13 When performing an ALT, the surgeon treats part of the eye, then wants to return later to treat the rest. Are both laser treatments billable?

107 Code This Superbill #14 Monocular patient with end stage glaucoma and a pinpoint island on a GVF failed prior trab Decision to implant BV 35 GDD as a staged procedure

108 Code This Superbill #14 Stage 1 BV 35: Shunt, external approach with graft, or with graft

109 Code This Superbill #14 Stage 2 SPG How should this be coded? Scleral reinforcement with graft Aqueous shunt, external approach, with graft Modifier? -58, -78

110 Questions

111 AGS 215 PQRS Value-Based Modifier

112 PQRS 215 Synonyms: Burdensome, arduous, strenuous, difficult, hard, heavy, back-breaking, oppressive, weighty, uphill, challenging, formidable, laborious, Herculean, exhausting, tiring, taxing, demanding, punishing, grueling, wearing, wearisome, fatiguing, toilsome

113 PQRS 215 Medicare Part B Medicare as a secondary payer Railroad Medicare Medicare Advantage Plans depending upon your contract with them.

114 215: Penalties PQRS -2 percent in 217 Value-Based Modifier *based on 215 PQRS reporting and cost of care -2 percent in 217 (groups of <1 and solos) -4 percent in 217 (groups of >1 or more) EHR Incentive Program -3 percent in 217 ASCQRS -2 percent in 217

115 PQRS 215 Options to avoid the 2 % 217 PQRS penalty:

116 PQRS Claims Reporting Report 9 measures across three domains including at least one crosscutting measure. There are 11 measures that can be reported via claims.

117 PQRS EHR Reporting Report 9 measures in 3 quality domains from January 1 December 31 If EHR does not contain patient data for at least 9 measures covering 3 domains, then EP reports all of the measures for which there is Medicare patient data. Required to report on at least 1 measure for which there is Medicare data.

118 PQRS IRIS Registry A. EHR Extraction (June 1) If planning to report MU Stage 2 Menu Measure 6, must register by March 1 B. Cataracts Measures Group (Aug. 1) C. Non-EHR Web Portal Entry (Oct. 31)

119 The Value of IRIS Registry Regulatory Compliance Benefits The IRIS Registry can report on your behalf to satisfy the requirements of the Physician Quality Reporting System. The IRIS Registry can report on your behalf to satisfy the requirement to report Meaningful Use CQMs if you have an EHR. Participation in the IRIS Registry satisfies the Meaningful Use, Stage 2, Menu Objective 6 for reporting to a specialized registry. Reduces the reporting burden for you and your office. The Academy will update the IRIS Registry as needed and keep you informed of any regulatory changes. The IRIS Registry submits the data required to meet new criteria, with no extra work on your part.

120 PQRS 215 A. IRIS Registry EHR Extraction To report once for PQRS and Meaningful Use: IRIS Registry participants can report the 9 Meaningful Use ecqms If EHR does not contain patient data for at least 9 measures covering 3 domains, then EP reports all of the measures for which there is Medicare patient data. Required to report on at least 1 measure for which there is Medicare data. *Register for IRIS by June 1, 215 *Register for IRIS by March 1, 215 to report MU Stage 2 Menu Measure 6

121 PQRS 215 IRIS Registry EHR Extraction: ChartLogic Compulink eclinicalworks EyeDoc EMR Eyefinity ExamWRITER EyeMD EMR Doctorsoft First Insight GE Centricity EMR HCIT EHR ifa EMR IO Practiceware imedicware Integrity EMR for Eyes KeyChart EMR ManagementPlus Medinformatix EHR MDIntelleSys MDoffice Medflow NextGen NexTech SRS VersaSuite Vitera Intergy EHR WebChart by MIE

122 PQRS 215 B. Cataracts Measures Group Report through a qualified CMS registry (IRIS Registry) from approximately January 1 through September 3 on 2 patients, of which at least 11 must be Medicare Part B patients. Must have surveys prior to surgery. *Register with IRIS by August 1, 215

123 Cataracts Measures Group Measure 13 Measure 191 Measure 192 Measure Measures/2 Patients Documentation of Current Medications in the Medical Record *New to group Cataracts: 2/4 or Better Visual Acuity within 9 Days Following Cataract Surgery Only surgeons can report Cataracts: Complications within 3 Days Following Cataract Surgery Requiring Additional Surgical Procedures Only surgeons can report Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention *New to group

124 Cataracts Measures Group 8 Measures/2 Patients Measure 33 Measure 34 Measure 388 Measure 389 Improvement in Patient s Visual Function within 9 Days following Cataract Surgery Patient Satisfaction within 9 Days Following Cataract Surgery Cataract Surgery with Intra-Operative Complications (Unplanned Rupture of Posterior Capsule Requiring Unplanned Vitrectomy) *New to group Cataract Surgery: Difference Between Planned and Final Refraction +-1,D *New to group

125 PQRS 215 C. IRIS Registry Web-Portal Entry (no EHR) Traditional Qualified Registry: Report 9 measures in 3 quality domains, including 1 cross cutting measure For at least 5% of Medicare Part B FFS patients seen from January 1 through December 31 OR QCDR: Report 9 measures in 3 quality domains, including 2 outcomes measures* For 5% of all patients seen from January 1 through December 21. If 2 outcomes measures are not available, report 1 outcomes measure and 1 patient experience or efficiency measure. Register for IRIS by October 31, 215 *IRIS Registry expects to have 2 outcome measures for all sub-specialties, except for cornea and refractive, but they can likely report cataract measures.

126 Quality Domains Patient Safety Communication and Care Coordination Patient and Family Experience Community/ Population Health Efficiency Clinical Process and Effectiveness

127 PQRS Measures 215 Ophthalmology Individual Measures 12 POAG: Optic Nerve Evaluation Effective Clinical Care Claims, Registry, EHR 14 AMD: Dilated Macular Examination Effective Clinical Care Claims, Registry 18 DR: Documentation of Presence or Effective Clinical Care *EHR Absence of Macular Edema and Level only of Severity of Retinopathy 19 DR: Communication with the Physician Managing Ongoing Diabetes Care Effective Clinical Care Claims, Registry, EHR 117 Diabetic Eye Exam Effective Clinical Care Claims, Registry, EHR

128 PQRS Measures 215 Ophthalmology Individual Measures 137 Melanoma: Continuity of Care Recall Communication and Care Coordination 138 Melanoma: Coordination of Care Communication and Care Coordination 14 AMD: Counseling on Antioxidant Supplement 141 POAG: Reduction of IOP by 15% OR Documentation of a Plan of Care 191 Cataracts: 2/4 or Better Acuity within 9 Days Following Cataract Surgery Effective Clinical Care Communication and Care Coordination Effective Clinical Care Registry Registry Claims, Registry Claims, Registry Registry, EHR, CMG

129 PQRS Measures 215 Ophthalmology Individual Measures 192 Cataracts: Complications within 3 Days Following Cataract Surgery Requiring Additional Procedures 224 Melanoma: Overutilization of Imaging Studies in Melanoma Patient Safety Efficiency and Cost Reduction Registry, EHR, CMG Registry 238 Use of High-Risk Medications in the Elderly Patient Safety Registry, EHR 265 Biopsy Follow-up Communication and Care Coordination 384 Adult Primary Rhegmatogenous Retinal Detachment Reoperation Rate: % of Surgeries where Retina Remains Attached After Only One Surgery *New Measure Effective Clinical Care Registry Registry

130 PQRS Measures 215 Ophthalmology Individual Measures 385 Adult Primary Rhegmatogenous Retinal Detachment Surgery Success Rate: % Achieving Flat Retina 6 mo Post Surgery *New Measure 388 Cataract Surgery with Intra-Operative Complications (Unplanned Rupture of Posterior Capsule Requiring Unplanned Vitrectomy) *New Measure 389 Cataract Surgery: Difference Between Planned and Final Refraction: % Achieving Planned Refraction within +- 1,D *New Measure Effective Clinical Care Patient Safety Effective Clinical Care Registry Registry, CMG Registry, CMG

131 PQRS Measures 215 Cross Cutting Measures 11 Preventive Care and Screening: Influenza Immunization E/M codes 1Q and 4Q document once per pt 111 Pneumonia Vaccination Status for Older Adults E/M Codes for the yr 13 Documentation of Current Medications in the Medical Record Community / Population Health Community / Population Health Patient Safety Claims, Registry, EHR Claims, Registry, EHR Claims, Registry, EHR 318 Falls Screening for Falls Risk Patient Safety EHR

132 PQRS Measures 215 Cross Cutting Measures 226 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention 236 Controlling High Blood Pressure E/M codes Community / Population Health Effective Clinical Care 374 Closing the Referral Loop Communication and Care Coordination 42 Tobacco Use and Help with Quitting Among Adolescents Community/ Population Health Claims, Registry, EHR, CMG Claims, Registry, EHR EHR EHR

133 New! PQRS Measures 215 IRIS Registry Measures IRIS Registry expects to have up to 18 additional ophthalmology-specific measures that can be reported for PQRS. Only IRIS Registry participants will have the option to report these additional measures.

134 PQRS GPRO Reporting Large, multi-specialty practices may want to report as a group practice GPRO (instead of individual EPs), and should register as GPRO reporting.

135 What if I don t have 9 measures? Claims and Registry: Physicians can report fewer than the required number of measures or measures in fewer than 3 quality domains. You will be subject to measure applicability validation (MAV) to ensure they have reported on all available measures.

136 PQRS 215 ICD-1 Measure Specifications Begin reporting in ICD-1 on October 1, 215.

137 PQRS 215 Physicians who submit PQRS data via claims will have access to a quarterly report to verify the status of their data submissions. 215 first quarter reports will be made available in summer 215. To access your report, log in to the QualityNet portal with your IACS login.

138 Questions PQRS IRIS Registry IRIS Registry PQRS/VBM EHR

139 Audits: It s Not a Matter of If, But When

140 OIG Report Medicare Paid $22 Million in 212 for Potentially Inappropriate Ophthalmology Claims. Fraction of the approximately $8.2 billion Medicare paid ophthalmologists in 212 to, screen for, diagnose, evaluate, or treat cataracts, wet age-related macular degeneration, and glaucoma

141 OIG Report No actual physician chart notes were reviewed. Data from Medicare Administrative Contractors (MACs) MACs are held responsible for many of the inappropriate payments due to poor oversight of their own Local Coverage Determinations (LCDs).

142 OIG Report However MACs may now choose to take further action by recouping inappropriate payments. Through Recovery Audits?

143 OIG Report Cataracts Medicare paid approximately $3.5 billion in 212 for exams that screen for, diagnose, evaluate, or treat cataracts. There is a national requirement which states that, Medicare will not routinely cover more than one comprehensive eye examination and scan for patients whose only diagnosis is cataract. MACs erroneously paid 1,56 times for more than one cataract surgery per eye in the same year.

144 OIG Report Glaucoma Approximately $1.3 billion in 212 was paid by Medicare to screen, diagnosis, evaluate and treat glaucoma. Glaucoma screening tests billed for patients who had already been screened within the past 12 months.

145 Good News!

146 Comprehensive Error Rate Testing (CERT) Report Ophthalmology Leads Medical Specialties in Accurate Medicare Claims Ophthalmology ranks among the best of all medical specialties in submitting accurate Medicare claims, according to the 214 CERT report. Overall, the error rate for ophthalmology specific eye surgeries is 2.9%, and cataract is 4.1%.

147 Comprehensive Error Rate Testing (CERT) Report The report also indicates that of all specialty groups providing all Medicare Part B services, ophthalmology has one of the lowest error rates, at just 3.5%. National average error rate, is 12.2%. The only other specialty group with a low error rate is thoracic surgery, which is.4%.

148 Comprehensive Error Rate Testing (CERT) Report Exclusive of evaluation and management office visits, ophthalmology has no services on the list of top-2 services with coding errors.

149