Article Date: 2/1/2008

Timing is Everything
billing & coding

Timing is Everything

Why every optometrist should consider participating in PQRI.


Just like a first kiss, timing is everything when it comes to embracing Medicare's relatively new program, the Physician Quality Reporting Initiative. PQRI is the Centers for Medicare & Medicaid Services' (CMS) step toward aligning payment with quality to improve patient care. You have the best opportunity to take advantage of CMS's quality improvement program, now at the beginning of the new year. In late March, joining your colleagues in increasing Medicare payments will be impractical.

The rules to qualify for the PQRI bonus payment aren't complex, but they do require your scrutiny. (Visit for more information.) Medicare is interested in certain diagnosis codes. Under PQRI, when you submit one of these diagnosis codes on a claim form (in combination with an office-call code), you also report an additional special current procedural terminology (CPT) code. This special code communicates to Medicare what procedure you did. If you add this special CPT code to eight or more claims out of 10 that have the particular diagnosis code, Medicare pays the bonus.

The method Medicare uses to calculate the 80% minimum reporting rate may surprise you. The "numerator" is the number of PQRI reports you submit. The "denominator" is the number of opportunities that you can submit a report, as is indicated by the diagnosis code. The less obvious part: Medicare counts your reporting opportunities starting Jan. 1, 2008. Every reporting opportunity counts toward your "denominator."

"Optometrists need to be in the medical game."

Wait a minute

You're no doubt asking yourself: If I sign up for the PQRI program in March 2008 won't Medicare count the denominator then? Trick question. You don't have to sign up for PQRI participation. Participation begins the first time you report the special CPT codes, according to Medicare. However, regardless of whether you submit PQRI reports, Medicare's meter counts each time a designated diagnosis code passes through the payment system to use it, if needed, to calculate your reporting percentage.

By March's second week, 20% of the year is gone along with 20% of your yearly patient volume.

Let's say you start reporting the special codes on March 10 when you have yet to see 80% of your patients. To reach the 80% reporting level, you must report every one of your opportunities throughout the rest of the year, until December 31, 2008. The middle of March becomes a de facto deadline to participate in the PQRI program and qualify for payment.

Voluntary or mandatory?

The Physician Voluntary Reporting Program (PVRP) in 2006 (predecessor to PQRI) was voluntary and non-paid. PQRI 2007 also was voluntary (and the first reporting program Medicare budgeted for payments).

CMS says that the 2008 PQRI is a voluntary reporting program. In other words, you don't have to submit PQRI reports unless you want to. What about 2009 and beyond? Despite persistent rumors, no CMS publication suggests PQRI will become mandatory next year or in the future.

The decision to participate is an individual one. But let us be reminded by my friend and astute observer, Hans Kell, O.D., of Louisville, Colo., who says, "Optometrists need to be in the medical game." A high level of volunteerism in the PQRI program shows we support, in good faith, Medicare's endeavor to increase the quality of care for Medicare beneficiaries. Our participation supports the concept that optometrists are an integral, necessary part of the medical community. So, let us embed in the minds of medical-plan administrators that optometry is associated with medical eye care.

Who can participate?

If you're a Medicare-enrolled optometrist, you may participate, regardless of whether you've signed a Medicare participation agreement to accept assignment on all claims. PQRI literature advises that only "eligible professionals" may participate in PQRI. However, one means of becoming eligible is simply by being an optometrist, according to the CMS definition.


Medicare implemented the 2006 PVRP as the first step toward "pay for performance" for physician services. The second step is PQRI, a "pay for reporting" program. There is a clear distinction between not-yet-here "pay for performance" and the current "pay for reporting" programs: With PQRI, CMS issues payment for submitting data, not for services rendered. You are required to only report whether you rendered the performance measures. By adding an extra CPT code on the claim form, you earn a lump-sum bonus of about 1.5%. That's 1.5% of all approved Medicare claims, including claims that have nothing to do with this year's five eyecare measures; plus, the bonus calculation includes the 20% portion the beneficiary pays.

With extra payment resulting from an extra stroke of your pen and participation aligning optometry with medical care, PQRI is truly a no-brainer. OM


Optometric Management, Issue: February 2008