How one PQRS diabetes code can save you future penalties

If you treat even a single Medicare patient with diabetes during the remainder of 2013, you can avoid penalties coming in 2015.

"Practitioners have reasons to make a real effort to use PQRS codes on a regular basis."

All that is necessary to avoid having Medicare reimbursements docked 0.5 percent in 2015 under the Physician Quality Reporting System (PQRS) is "a good-faith effort" to provide quality patient care.

Medicare has indicated a good-faith effort can mean as little as providing PQRS quality of care measures to a single appropriate patient over the course of a year. So all practitioners need to do is use the PQRS codes once—on one claim for one patient —during 2013 to avoid the PQRS payment penalty in 2015.

"Although, with Medicare planning to increase its quality reporting requirements over coming years, practitioners have reasons to make a real effort to use PQRS codes on a regular basis," said Rebecca Wartman, O.D., AOA Third Party Center Executive Committee member. "By doing so, practitioners could not only avoid the coming PQRS payment penalty but quite possible still earn a PQRS bonus this year."

PQRS, diabetes and related eye conditions

You can meet any of the following PQRS measures based on how you handle the status of a patient's diabetes and related eye conditions:

  • No. 18: Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level of Severity of Retinopathy
  • No. 19: Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care
  • No 117: Diabetes Mellitus: Dilated Eye Exam

Basically, the PQRS program encourages practitioners to provide any patient, age 18 to 75, who has insulin or non-insulin dependent diabetes with a dilated macular or fundus examination. You must report the results to the patient's care provider or explain why you did not provide such an examination.

You can report compliance with measures No. 18 or 19—using QDC 2021F, QDC 5010F and G8397 or G8398—when providing a patient 18 or older with diabetes a dilated eye exam. These codes are used only when diabetic retinopathy is present. Perform the exam, then document the presence or absence of macular edema and the level of diabetic retinopathy using the diagnosis codes.

The following diabetic retinopathy diagnoses are the only ones that apply to these measures:

  • 362.01 Background Diabetic Retinopathy
  • 362.02 Proliferative Diabetic Retinopathy
  • 362.03 Nonproliferative Diabetic Retinopathy, not otherwise specified
  • 362.04 Mild Nonproliferative Diabetic Retinopathy
  • 362.05 Moderate Nonproliferative Diabetic Retinopathy
  • 362.03 Severe Nonproliferative Diabetic Retinopathy

Note that diabetic macular edema (362.07) is not one of the listed codes. Take these steps to properly code for macular edema:

  1. Report the systemic diabetes diagnosis (250.00)
  2. Report the proper diabetic retinopathy diagnosis
  3. Report the diabetic macular edema diagnosis

Only link measures No. 18 and 19 to the applicable diabetic retinopathy codes. Do not link the 2021F to the systemic diabetic diagnosis or to the macular edema diagnosis.

The exceptions for 2021F are as follows:

  • 1P - Medical reason not for documenting macular edema and diabetic retinopathy
  • 2P - Patient reason for not documenting macular edema and diabetic retinopathy
  • 8P - No reason for not documenting macular edema and diabetic retinopathy

Measure No. 19 uses three different QDCs. Code 5010F indicates you have communicated the presence or absence of macular edema and the level of diabetic retinopathy to the physician responsible for a patient's diabetic care. Again, the same diabetic retinopathy diagnoses for measure No. 18 apply to this measure.

In addition, you must indicate whether a dilated macular or fundus examination was performed. The QDC options for this information are:

  • G8397, indicating the dilated macular or fundus exam was performed
  • G8398, indicating the dilated macular or fundus exam was not performed

There are no exceptions for G8397 and G8398. However, there are two exceptions for 5010F:

  • 1P - medical reason for not communicating
  • 2P - patient reason for not communicating
  • 8P - no reason for not communicating

Dilated exams for patients with diabetes

Measure No. 117 uses one of four QDCs to indicate a dilated diabetic examination was performed. This measure is used only for patients ages 18 to 75. It is used for an expanded list of diagnoses, including the following:

  • 250.00-250.03, 250.10-250.13, 250.20-250.23, 250.30-250.33, 250.40-250.43, 250.50-250.53, 250.60-250.63, 250.70-250.73, 250.80-250.83, 250.90-250.93, 357.2, 362.01-362.07, 366.41, 648.01-648.04.

Diagnoses 250.00-250.03, 250.50-250.53, 362.01-362.07 are more commonly used by eye care providers. Remember to link the QDC to only one diagnosis code.

Use one of the following QDCs to report this measure:

  • QDC 2022F—dilated eye exam performed on a diabetic patient by an optometrist or ophthalmologist
  • QDC 3072F—used when the patient is at low risk for diabetic retinopathy, indicating the patient had a normal examination without diabetic retinopathy within the last year

There are two other codes for imaging views of the retina for measure No. 117—QDC 2024F and QDC 2026F—but they are not commonly used by eye care providers. Because most optometrists perform dilated diabetic examinations, 2022F would be more common than 2024F and 2026F.

The AOA offers additional resources related to PQRS measures (member log-in required).

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