PQRS in the Retina Practice

What it is, why it is important, and what it means for physicians.

By Paul Gallogly, MD

At a Glance

• Failure to report quality measures via the PQRS may result in a 2% to 4% reduction in reimbursement.
• Using an ophthalmology-specific EHR system can streamline the process of quality reporting.

The list of potential revenue killers for retina professionals in 2015 continues to expand. Currently, that list includes Meaningful Use, ICD-10, Physician Quality Reporting System (PQRS), and Value Based Payment Modifier (VBPM). Although this alphabet soup can be daunting, understanding it is necessary in order to avoid Medicare payment penalties.


In 2007, the Centers for Medicare and Medicaid Services (CMS) created the PQRS quality reporting program (called PQRI until 2011) with the intent to promote the reporting of quality information by eligible professionals (EPs), including Medicare physicians.

According to CMS, individual EPs and PQRS group practices should choose at least nine individual measures across three National Quality Strategy (NQS) domains or one measures group as an option to report on measures to CMS. Quality measures are indicators of the quality of care provided by physicians. They are tools that help to measure or quantify health care processes, outcomes, patient perceptions, and organizational structure, and to measure an office’s ability to provide high-quality, effective, safe, efficient, patient-centered, equitable, and timely health care.1 The US Department of Health and Human Services NQS priorities for health care are called domains. These assess quality improvement, which includes patient and family engagement; patient safety; care coordination; population or public health; efficient use of health care resources; and clinical process and effectiveness.2

In 2015, the number of measures was increased from three to nine across three domains, and one of the nine measures must be a cross-cutting measure (eg, 130 – documentation of current medications in the medical record, or 226 – preventive care and screening: tobacco use: screening and cessation intervention). Two new measures (384 and 385) specifically applicable to retina specialists added in 2015 apply to the success rate of retinal detachment surgery.

Various options exist to assist in reporting PQRS measures. Common examples include reporting through a registry from your electronic health record (EHR) system, claims-based reporting from your office, and individual measure reporting via the American Academy of Ophthalmology Intelligent Research in Sight (IRIS) Registry web portal. With a powerful EHR system that can handle structured data, reporting via a registry is generally the most efficient method; therefore, this article focuses on reporting through an EHR system. Practices forgoing the use of EHR systems face the daunting task of paper reporting. Each of the nine measures may include 10 to 20 yes or no answers. Therefore, depending on the number of patients in a practice, one could estimate 125 000 yes or no questions for the year, which could take a staff 1 to 2 weeks of full-time work to input.


Efficiency vis-à-vis PQRS reporting should be an important factor to consider when purchasing an EHR system because an EHR system that cannot handle or report these measures may mean extra hours of work and frustration for a retina practice.

Some retina practices have begun using EMA Ophthalmology (Modernizing Medicine), an EHR system built by ophthalmologists and specifically designed around the workflow of an ophthalmology office. The native iPad application and corresponding web version facilitate capturing the right patient information at the right time and automate PQRS reporting and quality measures. EMA Ophthalmology was designed with unique technology that easily handles the VBPM. Physicians capture patient information on the iPad as structured data, which is automatically associated with the diagnosis, and the software pinpoints the location for accurate coding based on clinical findings. Physicians do not need to worry about further documenting medical necessity because such documentation is already built in. This is particularly important for retina specialists because EMA Ophthalmology can track patient outcomes and report quality of care without slowing productivity, meaning no staff needs to input data after the patient leaves the office.

In addition, Modernizing Medicine offers training webinars and PQRS experts to educate and support staff and an online forum where EMA Ophthalmology users can post questions and get answers to learn best practices from other users.


Failure to report PQRS measures will involve significant penalties as of 2015 and result in a 2% penalty of all Medicare Part B and Medicare payments as a secondary payer in 2017. In many ways, PQRS can be associated with the VBPM, which could potentially increase these penalties at some point in time from 4% to 6%, depending on the size of the medical practice group. (These percentages are based on a 2% PQRS penalty in addition to a 2% VBPM penalty for groups of one to nine providers and 4% VBPM penalty for groups of 10 or more providers). Assuming a practice collects $500 000 from Medicare, the PQRS penalty of 2% could cost a retina practice $10 000 for 1 year. And remember that other potential revenue killers (ie, Meaningful Use, ICD-10, and VBPM) could increase that number.


For practices using an EHR system, a registry makes the most sense for reporting PQRS measures, but physicians and staff must be trained on how to capture the data correctly. The most opportune time to capture data is during clinical hours while the patient is present, to avoid taking up valuable staff time inputting the data later. The most effective EHR systems aim to streamline this process as much as possible, but everyone on the staff must fully commit to using it to ensure successful reporting.

The penalty looming over the practice for failure to report should be enough incentive for all members of a retina team to be actively involved. Assigning one person within the practice as the go-to person for PQRS knowledge and one person as the EHR system “super user” creates in-house experts whom staff may contact with questions. Some EHR systems also provide PQRS assistance, which may help staff navigate the confusing PQRS maze.


Part of capturing the data correctly includes deciding which of the nine measures to report for your practice. This may not be obvious in a retina practice, but conforming to the available measures is necessary. The essential measures to report for a retina practice are 384 and 385; however, these are still based on the CPT code 67113 (Complex Repair of Retinal Detachment), so the retinal detachment repair must have occurred by June 2015 because these measures require the documentation of an attached or flat retina over a 6-month period.

PQRS and the other revenue killers can be frustrating, but the sooner retina specialists accept these inevitable changes in their field, the sooner they can adopt the technology that best ensures the profitability of their practices while also providing quality care. n

Paul Gallogly, MD, is a retina specialist at Retina Care Specialists in Palm Beach Gardens, Florida. He is the EMA Ophthalmology Team Lead, Posterior Segment, for Modernizing Medicine. Dr. Gallogly may be reached at paul.gallogly@modmed.com.

CPT codes copyright 2014 American Medical Association.

1. Centers for Medicare and Medicaid Services. 2015 Physician Quality Reporting System (PQRS): implementation guide. www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/2015_PQRS_ImplementationGuide.pdf.

2. Centers for Medicare and Medicaid Services. 2014 clinical quality measures. www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/2014_ClinicalQualityMeasures.html.


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About Retina Today

Retina Today is a publication that delivers the latest research and clinical developments from areas such as medical retina, retinal surgery, vitreous, diabetes, retinal imaging, posterior segment oncology and ocular trauma. Each issue provides insight from well-respected specialists on cutting-edge therapies and surgical techniques that are currently in use and on the horizon.