As part of the Centers for Medicare and Medicaid Services (CMS) Pay-for-Performance program for physicians, CMS will launch the 2007 Physicians Quality Reporting Initiative (PQRI) beginning July 1, 2007.

The PQRI is a “voluntary quality-reporting program” that rewards eligible providers with financial incentives for delivering high quality care, which is measured by selected “evidence-based standards and procedures.” PQRI is meant to encourage ongoing improvement that ensures high-quality care.

The PQRI includes 74 quality measures; 8 are specific to ophthalmology (Measures 12-19, see below for list). Download the “2007 PQRI Measures Specifications” that is posted on the CMS PQRI website. This detailed document includes descriptions, instructions, G-Codes, CPT Codes, rationale and clinical recommendations. Always refer to the CMS PQRI Website as your source for accurate, up-to-date information about Pay-for-Performance and the PQRI.

CMS is developing a comprehensive educational program for PQRI that will assist doctors and other eligible professionals with submitting data on measures, understanding the bonus payment and cap calculation, and accessing provider feedback reports. CMS will widely announce this to the provider community and will post details on the CMS PQRI website.

Listed below is a summary of the eight ophthalmology PQRI measures and important PQRI facts. Don’t forget to check out the American Academy of Ophthalmology (AAO) website and download the AAO’s “PQRI: Guide to Implementation.”

PQRI Quality Measures Summary:

• Measure #12: Primary Angle Glaucoma: Optic Nerve Evaluation



• Measure #13: Age-Related Macular Degeneration: Age-Related Eye Disease Study (AREDS) Prescribed/Recommended



• Measure #14: Age-Related Macular Degeneration: Dilated Macular Examination



• Measure #15: Cataracts: Assessment of Visual Functional Status



• Measure #16: Cataracts: Documentation of Pre-surgical Axial Length, Corneal Power Measurement and Method of Intraocular Lens Power Calculation



• Measure #17: Cataracts: Pre-surgical Dilated Fundas Evaluation



• Measure #18: Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level of Severity of Retinopathy



• Measure #19: Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care

PQRI Quick Facts:

• Registration is not required to participate.



• Reporting period is July 1, 2007 through December 31, 2007.



• The bonus is contingent on achieving 80% success for patients that have a disease/diagnosis that a quality measure you selected is reported (e.g., examining the optic nerve for a glaucoma patient), and achieving that success rate for three quality measures (or fewer measures if less apply).



• Doctors who successfully designate a set of quality measures on claims may earn a bonus payment, subject to a cap, of 1.5% of the total allowed charges for covered Medicare physician fee schedule service.



• The initiative is not applicable to the Medicare Advantage programs, including the private fee-for-service plans. It also doesn’t apply to Medicaid patients.



• Zero-dollar amounts are listed in the Medicare Fee Schedule for Category II codes. The submitted charge/line item field cannot be left blank. Since some practice management systems will not accept a zero charge, post $0.01.



• For claims submitted on the CMS 1500 Form, procedures codes are reported in field 24D.



• Bonuses will be paid out as a lump sum in mid-2008. All bonus incentive payments earned will be paid for each tax identification number (TIN).