PQRS for Optometry

OK last time we broke down PQRS for mental health and we got lots of feedback stating how helpful it was.  So now we are going to break it down for Optometry providers.

Just a quick recap for those who still don’t know what PQRS is:  PQRS or Physician Quality Reporting System is a system used by physicians to report performance measures to Medicare.  Prior to 2015 PQRS was simply an incentive program (known as PQRI).  But in 2015 it will become a penalty program.  Physicians who do not report performance measures using PQRS will be faced with a 1.5% penalty in 2015 and a 2% penalty in 2016.  Even though the penalty program doesn’t start until 2015 the penalty is based on reporting done in 2014 so in order to avoid the penalty providers must be reporting performance measures now.

The PQRS program is for Fee-For-Service Medicare patients.  It does not include patients who are enrolled in Medicare Advantage Plans, or Part C Medicare.  So let’s break this down and make it as simple as we can.  (Don’t forget, it is a government program.  They don’t usually make anything easy.)

Let’s break the whole process down into 3 steps:

1.    Identify the measure you will use to report
2.    Link the chosen measure to the appropriate reporting code
3.    Report them to Medicare

  1. Identify the measure you will use – CMS has over 300 reporting measures but (thankfully) most are not relevant for optometry. There are 14 measures that appear appropriate for optometry with 7 of those 14 being specific to eye care. Here are the 14 appropriate measures:
  1. 12   Primary Open Angle Glaucoma (POAG): Optic Nerve Evaluation
  2. 14   Age Related Macular Degeneration (AMD): Dilated Macular Examination
  3. 18   Diabetic Retinopathy: Documentation of Presence or Absence of Macular

Edema and Level of Severity of Retinopathy

  1. 19   Diabetic Retinopathy: Communication with the Physician Managing On

going Diabetes Care

  1. 110 Preventive Care and Screening: Influenza Immunization
  2. 111 Pneumonia Vaccination Status for Older Adults
  3. 117 Diabetes: Eye Exam
  4. 128 Preventive Care and Screening: Body Mass Index (BMI) Screening and


  1. 140 Age-Related Macular Degeneration (AMD): Counseling on Antioxidant


  1. 141 Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure

(IOP) by 15% OR Documentation of a Plan of Care

  1. 173 Preventive Care and Screening: Unhealthy Alcohol Use – Screening
  2. 226 Preventive Care and Screening: Tobacco Use: Screening and Cessation


  1. 236 Controlling High Blood Pressure
  2. 317 Preventive Care and Screening: Screening for High Blood Pressure and

follow –up documented

  • Remember, the performance measure must be reported using the appropriate g-code or CPT-II code, but the actual results do not get reported.
  1. Link the chosen measure to the appropriate reporting code – Find the appropriate G-Code or CPT II code to report the measure. Make sure the procedure code that is being billed is appropriate for the measure being reported. See the table from CMS below:

(* Please note that this information is always changing. Please check the CMS website to make sure that you are using the most up to date codes.)

Click here to download chart of the measures and appropriate codes.

  1. Report the measures to Medicare – Measures can be reported to Medicare in one of four different ways:
  2. Claims based reporting – codes are included on the claim for the services
  3. Registry based reporting – measures are reported to large Medicare approved organizations that report the data to Medicare
  4. EHR based reporting – measures are reported through the EHR system
  5. Group practice reporting – measures are reported through a group practice

The most common reporting method is claims based reporting. Claims based reporting is done by adding a G-Code or a CPT II code to the claim. Once the appropriate code is selected it is billed on the same claim as the services. The code must be entered with either a $0.00 or a $0.01 charge. (Nothing is paid on the code. Some systems will not allow it to be entered with a $0.00 charge so a $0.01 charge must be used. It will depend upon the system being used to create the claim.)

So now that we have covered the steps of PQRS, let’s go through a couple of examples:

Example 1: Doctor sees a glaucoma patient who is 18 years of age or older.   The doctor should perform an optic nerve evaluation at least yearly and would measure the intraocular pressure at least yearly.   When the IOP is not controlled, a provider would typically develop a plan to reduce the IOP to an acceptable level. The doctor could code a 2027F and a 3284F for a controlled glaucoma patient or 2027F, 0517F and 3285F together for an uncontrolled glaucoma patient.

Example 2: Doctor sees a diabetic patient, with or without diabetic retinopathy, between 18 and 75 years. The PQRS code 2022F would indicate a dilated eye examination was performed (assuming that the provider would typically dilate all diabetic patients yearly). Also, when diabetic retinopathy (with or without macular edema) is found, the doctor would use 2021F to indicate a dilated macular or fundus examination was performed.

If the doctor sent a report to the patient’s primary care doctor he would also use 5010F to indicate a report was sent along with G8397 to again indicate the dilated macular or fundus examination was performed. ** This can only be done if the patient was 18 and older.


4 Responses to “PQRS for Optometry”

  1. Elizabeth Caissie Says:

    Here’s my question: I bill for several physical therapy providers who are already reporting G-codes as part of functional reporting. The first time I called and inquired about PQRS I was told that those G-codes were sufficient; the second time I was told, no they weren’t. So I don’t know if we need to do additional reporting or not. I’ve enrolled one provider in PQRS Pro, but I haven’t gotten very far – most of the measures don’t seem to apply to PT.

    Can you shed any light on whether the G-codes we are already reporting are sufficient?

    • solutionsmedicalbilling Says:

      Did your providers receive letters from Medicare stating they are not complying? Our providers who are complying did not receive letters.

      • Elizabeth Caissie Says:

        The one in New Jersey just did about two weeks ago…that was way past the time that I learned that we have to file. But the letter was for LAST year’s filing to state that she will receive a 1.5% penalty for next year. We’ve joined a registry and will be filing 2014 measures for 2016 rates, but both providers are having trouble finding measures that are applicable, and I had one of the people I called agree with me; they’re just aren’t whole lot for physical therapy. In addition to that, we are already reporting G-codes for functional limitations, which are different than the G-codes for PQRS (which was where some of my confusion lay). I think at the very least that if they are for two different purposes, they should call them two different things.
        Thanks for your help!

  2. Terese Ristem Says:

    This is great!!! Thank you!!

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