CMS releases information on Part B claims-based quality measure scoring for 2021
Excerpted from page 46 of the September/October 2021 edition of AOA Focus.
Written by the AOA’s Coding & Reimbursement Committee.
The Centers for Medicare & Medicaid Services (CMS) has announced that it has found issues with two quality measures that are sometimes reported by doctors of optometry. This is an issue on the CMS side and not due to physician error. The two measures impacted are:
- Quality ID 001: Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)
- Quality ID 117: Diabetes: Eye Exam
The issue identified only impacts those who are reporting these measures via Part B claims. There was a CMS system processing error that caused rejections of certain quality data codes for these two measures. The codes impacted are included below.
If you report one of the delineated codes, CMS will not score the corresponding measure for 2021. CMS will reduce the “total available measure achievement points” by 10 points for 2021 for those doctors who reported either of these measures and reported one of the noted quality data codes.
The quality data codes impacted are as follows:
|Measure QID||Measure Name||Affected CPT II Quality Data Code|
|001||Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)||3051F - Most recent hemoglobin A1c (HbA1c) level greater than or equal to 7% and less than 8%.|
|001||Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)||3052F - Most recent hemoglobin A1c (HbA1c) level greater than or equal to 8% and less than or equal to 9%.|
|117||Diabetes Eye Exam||2023F - Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed; without evidence of retinopathy.|
|117||Diabetes Eye Exam||2025F - Seven standard field stereoscopic photos with interpretation by an ophthalmologist or optometrist documented and reviewed; without evidence of retinopathy.|
|117||Diabetes Eye Exam||2033F - Eye imaging validated to match diagnosis from seven standard field stereoscopic photos results documented and reviewed; without evidence of retinopathy.|
CMS has indicated if the code for the measure was not included in the list above (e.g., 2022F for the Diabetes: Eye Exam measure) you will still be scored for the measure. While CMS encourages reporting other quality measures for the year, doctors can still earn perfect scores by reporting other measures at high performance levels.
As a reminder, quality scores are assessed using the following formula:
Ask the coding experts
If you have any questions regarding Medical Records and Coding, please submit them by using the Coding Experts Submission Form and one of our coding experts will be in contact with you.
Changes in coding and reimbursements worth knowing. Meanwhile, with the clock winding down on 2024, the AOA continues to press for Congress to act on reforms that would give doctors of optometry an annual, permanent inflationary Medicare payment tied to the Medicare Economic Index.
The federal government and private payers are heavily scrutinizing the use of modifier -25. When used appropriately, it can help to ensure that patients receive appropriate treatment and that doctors of optometry are reimbursed appropriately for their service. If you believe a claim that includes modifier -25 was inappropriately denied, follow appropriate criteria when appealing.