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More details on Medicare's PQRI

From the June ACP Observer, copyright © 2007 by the American College of Physicians.

By Brian Whitman

Practice RxLast month, this column reviewed many of the elements of the Medicare Physician Quality Reporting Initiative (PQRI). This month’s column takes a closer look at the measure specifications that will explain exactly how to participate.

Q: I forgot what this program is. Remind me.

A: The PQRI is a new Medicare program starting on July 1 that will pay physicians a bonus for reporting on quality measures through the claims system. The bonus will be equal to 1.5% of Medicare allowed charges during the reporting period of the last six months of 2007 and will be paid in a lump sum in the middle of 2008.

Q: I understand that I have to report on at least three measures for 80% of eligible patients. How do I know what patients are eligible?

A: The CMS has released a detailed list of measure specifications available at www.cms.hhs.gov/PQRI/Downloads/Specifications_2007-02-04.pdf. For each of the 74 available quality measures there is a list of current procedural terminology (CPT) codes, International Classification of Disease (ICD-9) codes, and patient demographics (age, gender) that would indicate if the patient should have a measure reported, provided that it was selected by the physician.

Q: How is 80% measured?

A: The numerator of that fraction is the number of times that a specific measure was reported. The denominator is the number of your clinical encounters with patients that meet the criteria listed in the measure specification.

Measure #51 offers a good example of the way the system will work. This measure intends to assess spirometry evaluation of patients with a diagnosis of chronic obstructive pulmonary disease (COPD). Measure #51 would be reported on all patients that receive an outpatient evaluation and management (E/M) service other than a consultation that were diagnosed with an ICD-9 code from the following list: 491.0, 491.1, 491.20, 491.21, 491.22, 491.8, 491.9, 492.0, 492.8, and 496. If you were to select spirometry, you would be required to report it 80% of the time it applied to count toward receiving the bonus.

Q: What if one of the above is a secondary or tertiary diagnosis?

A: If an ICD-9 code is reported on the claim form on any line, it will be included in the calculation. Physicians should not report diagnosis codes for symptoms or diseases they do not address at that visit.

Q: How do I report the quality measure?

A: Measures will be reported using either CPT Category II codes or Medicare-created G-codes in cases in which CPT Category II codes do not exist. For the example of spirometry, the physician would report the measure with CPT Category II code 3023F.

Q: What does it mean when I report code 3023F?

A: Coding 3023F on the billing submission indicates that spirometry results were reviewed and documented in the medical record.

Q: What if I did not review or document results?

A: A physician may report the code 3023F with a modifier to indicate why the measure was not performed. Using a modifier will exclude that particular case from the calculation of the denominator. There are four modifiers:

  • Modifier 1P indicates there are medical reasons why the spirometry was not performed and documented, such as a medical contraindication or extenuating circumstance that would make it inappropriate for the test to be performed.
  • Modifier 2P indicates there are patient reasons for the test not being performed, such as the patient refused it.
  • Modifier 3P indicates there are system reasons that explain why spirometry was not performed or documented, such as the test is unavailable. (This may be unusual to use for spirometry, but it may make more sense for other measures.)
  • Modifier 8P indicates the measure was not performed for reasons other than above.

Q: Can I use these modifiers for whatever measures I pick to use?

A: No. Each measure specification includes the modifiers that may be reported for the code. The modifiers are consistent from one code to the next, but you may not be allowed to report certain modifiers for certain measures.

Q: Spirometry is only indicated to be performed once a year. Does this mean that I have to perform and document a spirometry every time I see the patient even when it is not necessary?

A: No. CMS does not expect physicians to perform services that are not medically necessary to participate in the PQRI. If the patient is seen subsequent to the performance and reporting of the spirometry, the physician should not report a quality measure on that patient, even though the ICD-9 code reported is on the list above. This patient encounter would not be considered toward the denominator from which 80% would require a quality measure to be reported.

But, if the physician performed the procedure previously and sees the patient again, the physician should look back in the medical record to determine if it was documented within the past year. If it was, the physician should report the measurement code on the first claim submitted during the PQRI program.

Q: Since these new codes require a billing line, should there be a charge associated with them?

A: Generally, no. Physicians should assign a charge of $0.00 to these charges in order to submit them to Medicare. Some practice management systems, electronic clearinghouses, and Medicare secondary payers may not permit a physician to submit a charge of $0.00. If this is the case, physicians should assign a very small fee (e.g. $0.02) to the reporting measures. This claim will not be paid by Medicare, but it will allow the code to go through the system.

Q: I work for two different practices and they each chose different measures. Will I be able to reach the 80% threshold?

A: Physicians are judged individually and are allowed to choose their own measures, but groups may wish to choose measures collectively in order to ease the administrative burden. CMS will calculate successful participation on a National Provider Identifier/tax identification number combination. In the case of this question, there will be two different calculations. The first will address work with the first group and will only consider the measures chosen for that group. The second calculation will only consider the measures chosen for the second group. This means that you could be eligible for two separate bonus payments that would be directed to the group tax identification number. The same principle applies if you were to change from one group to another during the reporting period.

Brian Whitman is senior analyst for Regulatory and Insurer Affairs in ACP's Washington office.

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