PQRS Gets More Complicated


We are hearing that many providers are receiving letters stating that they are being penalized for not meeting the requirements of PQRS even though they thought they were reporting correctly. These providers report that they have been using claim based reporting all year on all Medicare claims but are now told they do not qualify.

It seems that the PQRS reporting rules are more difficult, and in some cases even impossible, to follow. For example, we have several LCSWs who report on depression screening and elder abuse. They report on every Medicare patient they see so they are definitely over the 50% mark. However they only report on those two measures since those are the only two applicable ones for their situation.

They too received notice that they did not meet the PQRS reporting requirements. We contacted the PQRS help desk and we were advised that the codes used by the LCSWs, 90791, 90834 & 90837, are eligible for reporting 8 measures and that all 8 measures must be reported. One of the eight measures is body mass index. Most LCSWs are not qualified to discuss BMI with a patient since their BMI may be affected by other medical health issues and/or medications they may be taking for health issues and the LCSW would not be qualified to discuss that with the patient.

Another one of the eight measures is blood pressure. Again, LCSWs are not trained to take and/or monitor blood pressure on patients. Most patients who see LCSWs go there to discuss issues in their life, not to have the LCSW discuss their blood pressure, medications, or BMI. The only recourse is to file an informal appeal. We have done that on behalf of several providers stating that the requirements are not within their scope of practice. It is unfair that LCSWs are going to be penalized for not reporting on measurements that are not within their scope of practice.

The eight measures that must be reported by a LCSW are Body mass index, Hypertension, Alcohol, Tobacco, Pain Assessment, Medications, and Elder Abuse.

While most therapists are likely to discuss depression and possibly elder abuse we have to wonder what hypertension, body mass index, tobacco, etc have to do with the therapy for a patient who is suffering from anxiety. And how is a social worker going to assess the medication needs of a patient they are counseling for problems at work. And yet all eight screenings are required in order to meet the PQRS requirements. Does it make sense? We are closely watching to see how MACRA ends up working out.


MACRA Made Easy – The Final Rule Released

On Friday October 14th CMS released the final rule of MACRA.  Since many providers and staff that we encounter still have not even heard of MACRA despite being bombarded with emails and newsletters with information, we will start at the beginning.

MACRA is The Medicare Access and CHIP Re-Authorization Act which was signed into law in 2015 and is slated to be implemented in 2019.  Even though it will not be implemented until 2019 it will be based on performance data from 2017.  Many providers seem to be ignoring the information on MACRA.  Maybe because they see the year 2019 and figure they still have time, or maybe because it is just too darn confusing to figure out.  In either case, ignoring MACRA can be a costly mistake.

Basically MACRA takes the Meaningful Use (MU) Electronic Health Record Incentive Program, Physician Quality Reporting System (PQRS), and the Value-Based Modifier (VBM) program and combines them all into one Merit-Based Incentive Payment System (MIPS) program.

What does that mean to providers or Eligible Professionals (EPs)?  Well it means that EPs will be assigned a MIPS composite performance score.  This score will be calculated on a scale from 0 to 100 and will significantly influence their Medicare reimbursements.  In 2019 a provider’s payments may be anywhere from -4% to +4% depending on their MIPS composite performance score.

The MIPS composite performance score will be divided into the following components:

60% Quality (PQRS)  –  If providers are not reporting PQRS then they are could have a score of 40 or below right off the bat.

25% Advancing Care Information – This was previously known as Meaningful Use or EMR.  If providers are not demonstrating Meaningful Use then they could lose 25 points of their MIPS composite performance score.

15% Improvement Activates  –  EPs will be able to choose from a list of activities that best fit their practice.  At least one activity must be selected.  The activities are categorized as “medium” or “high” weight.  Full credit for this portion of MIPS is 60 points.  A high weight category earns 20 points and a medium earns 10.  One way an EP can earn 60 points would be to participate in three high weight activities from the list.

MACRA replaced the old Sustainable Growth Rate (SGR) method of determining fee schedule amounts for providers.  Providers will now have fee schedules that will be determined by their MIPS composite performance score.  So it is possible that providers in the same physical location can have completely different reimbursement rates.  This is not simply a 1.5% or 2% penalty.  This will determine the fee schedule and may result in providers receiving up to -9% by the year 2022.

The problem is that the score will be based on data from two years prior so the provider will have to deal with the lower fee schedule for up to two years in order to rectify the situation.  Providers need to understand that the claims that they submit and the actions (or lack of action) they take beginning January 1, 2017 will affect their Medicare reimbursement in 2019.

If an individual EP works for more than one group, the performance score is a weighted average.  If the individual EP changes groups, the performance score is based on the data from the previous period.  So for example, if an EP works for Middleville Health Clinic for the entire year of 2017, but then switches to Johnstown Medical in 2018, their performance score for payments in 2019 will be based on their reported data from Middleville Health Clinic in 2017.

If an EP is newly enrolled, or they are below the low-volume threshold of $10,000 for the reporting year, then they will have no MIPS score and will be considered exempt for that year.
If an EP has Medicare billing charges less than or equal to $10,000 AND provides care for 100 or fewer Medicare patients in one year they are not subject to MIPS.

Doctors Face Another 1% Cut By Medicare

Congress has mandated adjustments to the MPFS, Medicare Physician Fee Schedule, for all eligible professionals providing covered services to Medicare beneficiaries who are not demonstrating meaningful use of EHR or Electronic Health Records.  These adjustments are effective January 1, 2015.

Some people read that above statement and are still scratching their heads as to what it means.  Why does CMS have to make things so difficult to understand?

Basically the government has taken another incentive program and turned it into a penalty program.  They have been trying for several years to get providers to use EHR in an effort to make patients health records more easily accessible.  They started out by offering monetary incentives to providers who voluntarily implemented EHR programs in their practices.  As with PQRS, the incentive program turned into a penalty program.  Any eligible professional who does not use EHR will be penalized by receiving a lower payment.

The penalties will be applied beginning January 1, 2015 and will be a 1% reduction.  So instead of allowing 100% of the Medicare allowed amount, providers who have not demonstrated meaningful use of an EHR will receive 99% of the allowed amount.   This is on top of the 2% being taken back for the sequester and the 1.5% penalty for PQRS.

What is meaningful use?  How does CMS know if a provider is demonstrating meaningful use?  Is this like Big Brother and they just know?  As with most of the government programs they do not make it easy for the provider to understand.  Actually providers who are using EHR must register that use with CMS at the following website:

We have found that many providers are actually using EHR but they didn’t know that they had to register their use.  EHR companies that are compliant with CMS have a code that they supply to the provider to input into the registration to show CMS which software they are using.

When it is spelled out in plain English it doesn’t seem like such a big deal.  But trying to wade through the government’s information about the program can seem overwhelming.

Providers who have not registered as using an EHR program received letters in the past few weeks advising them that they have been identified as an eligible professional who did not demonstrate meaningful use and therefore will be penalized the 1%.

If you or your provider has received this letter and you are using EHR then you need to register that use ASAP.  If the use is not registered then it doesn’t matter if you are using EHR, you will still be penalized.

Once the EHR use is registered the provider must complete the attestation to demonstrate meaningful use.  The attestation is a series of questions the provider must answer to show that their use of the EHR program complies with CMS’s guidelines for “meaning use”.  In order for a provider to avoid the penalty they must successfully register and attest to their use of EHR.

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.

Lots of Changes for 2014

It seems that this  year in particular there are so many changes in the field of medical billing that it is cause for concern in many medical offices.  With the implementation of the Affordable Care Act, (more commonly known as Obamacare)  (and what’s affordable about it??) the implementation of ICD10 diagnosis codes, the threat of being penalized for not satisfying the PQRS requirements and the newly revised CMS 1500 forms there is almost panic in many medical offices.

Everyone is asking how the Affordable Care Act is going to affect them and who really knows.  It’s going to cause more people to be covered with health insurance so there will be more doctor’s visits and more insurance billing to be done.  Other than that we don’t know what will happen.

The requirement to file claims on the newly revised CMS 1500 form requires new software.  This can be an expensive upgrade for many.  Some offices do not want to go through this and are looking for alternatives.

The implementation of ICD10 codes is going to be a challenge for many offices.  As we haven’t seen a change like this in many years it is difficult to predict how it will affect us.

Understanding PQRS

PQRS (Physician Quality Reporting System) is an extremely complicated system of reporting quality care for Medicare patients.  Originally it started as PQRI (Physician Quality Reporting Initiative), an initiative which paid an incentive to providers for using the reporting system.  It is now going to penalize providers who do not use the system by applying payment adjustments to physicians who do not satisfactorily report the quality measures.  PQRS applies to most providers who bill services for Medicare patients.
CMS states that the first step is to determine if the provider is eligible to participate in PQRS.  A list of PQRS eligible providers can be found at:

Next determine which reporting method best fits their practice.  There are four methods:

    Claims based
    Registry Reporting
    EHR Based Reporting
    Group Practice Reporting Option (GPRO)

Claims based reporting is the traditional reporting option.  It involves submitting CPT-II or G Codes on the Medicare claims for the patients being reported.  In order to qualify using the claims based option, an eligible provider must satisfactorily report on at least 50 percent of eligible instances.  (We are going to cover the claims based reporting option and the G codes in depth in our next newsletter.)

Registry Reporting is done through qualified registries.   Qualified registries are vendors that submit quality measure data to CMS using a source other than an EHR.  Providers would manually input or upload the patient data into the qualified registry.  The qualified registry then calculates the PQRS and submits those calculations to CMS.

EHR Based Reporting is done through an Electronic Health Record system.  Providers may submit PQRS measures through a qualified EHR system.  The qualified EHR system vendor would forward that data on to CMS.

Group Practice Reporting Option is done when a group of providers opts to participate in PQRS as a group practice.  The members of a group who opts into the Group Practice Reporting Option (GPRO) relinquish their right to participate in PQRS as an individual provider.  The PQRS incentive is then calculated based on the group’s total estimated Medicare Part B charges for the year.

Once the method is determined it is important to set up an office workflow to make sure the reporting is completed.  If using the traditional reporting option, or claims based reporting, then the codes used to report PQRS could be added to the encounter form.  If a paper encounter form is used then that would be fairly easy.  The provider can simply check off the appropriate reporting codes and the biller would simply add them to the claim when it is billed.  If the provider uses an electronic system then the codes need to be added to that system so that they can be reported on the claims.  The important thing is to establish a system to ensure that the PQRS reporting is done.

Providers do not need to notify CMS or their Medicare regional carrier prior to beginning reporting.  Simply add the codes to the claims and submit.  Many providers and billers are avoiding figuring out what PQRS is because it seems too complicated.   But avoiding it will end up costing the provider money.  How much money is lost will depend on how many Medicare patients the provider sees.

(Next newsletter will cover the claims based reporting method including the codes used in greater detail.)

Understanding PQRS

In order to keep from being penalized next year we will need to learn about the new PQRS or Physician’s Quality Reporting System. It is required by Medicare to report patient’s condition and treatment. The program is supposed to be an incentive by allowing for a small payment for participation but in 2015, next year, physicians will be penalized for not registering and participating in the program. This is quite complicated and covers many specialties as well as PCPs. It will amount to a secondary CPT code added to the claim. We will be offering more information on PQRS next month.

It is used to report not only the present condition of the patient to Medicare but the ongoing goals and how the patient is proceeding through the course of treatment.  This is only for Part B (professional services, Railroad Retirement and Medicare Secondary Payor by eligible providers. These eligible providers are:

Doctor of Medicine
Doctor of Osteopathy
Doctor of Podiatric Medicine
Doctor of Optometry
Doctor of Oral Surgery
Doctor of Dental Medicine
Doctor of Chiropractic

Physician Assistant
Nurse Practitioner
Clinical Nurse Specialist
Certified Registered Nurse Anesthetist (and Anesthesiologist Assistant)
Certified Nurse Midwife
Clinical Social Worker
Clinical Psychologist
Registered Dietician
Nutrition Professional

Physical Therapist
Occupational Therapist
Qualified Speech-Language Therapist