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PQRI improvements based on physician feedback, says CMS

From the April ACP Internist, copyright © 2009 by the American College of Physicians

By Brett Baker

Medicare’s pay-for-reporting program, the Physician Quality Reporting Initiative (PQRI), now in its third year, continues to evolve and while this evolution provides more and different options for physicians to report on quality measures, staying current on the rules and requirements can be a challenge.

Q: What is the status of the PQRI?

A: The basic rules remain the same since PQRI began in July 2007:

  • Physicians provide information on the extent to which they are furnishing care consistent with evidence-based clinical guidelines;
  • Physicians select the quality measures that are relevant to their practice; and
  • Physicians who successfully report on selected quality measures earn a bonus from Medicare.
PQRI improvements based on physician feedback, says CMS

Medicare tracks PQRI reporting at the individual physician level using each physician’s National Provider Identifier (NPI), and issues bonuses using the practice’s tax identification number. The practice receives a single check for an amount equal to the sum of the bonus earned by each member of the group.

Q: What do I need to know about the Medicare 2009 PQRI program?

A: Physicians have the opportunity to earn a PQRI bonus by reporting:

  • individual quality measures,
  • disease/condition-specific measures groups, and/or
  • data to a recognized registry that transmits the needed quality information to CMS.

Medicare will pay physicians who successfully report a bonus of 2% (up from 1.5% in previous years) of their total Medicare allowed charges during the reporting period. ACP estimates the bonus to be approximately $4,000 for the typical internist who successfully reports over the full 12-month period (and about $2,000 over a six-month reporting period). Medicare plans to make bonus payments in mid-2010.

Q: How do I determine the best reporting method option for me?

A: There are three reporting options:

  • individual quality measures,
  • disease/condition-specific measures groups, and
  • reporting through registries.

Internists who choose this option typically need to report on three individual quality measures because there are multiple measures for common conditions, such as diabetes, and because of the wide range of conditions internists treat. For each eligible encounter, physicians select the appropriate quality procedure code that pertains to a quality measure and include it on the claim used to bill Medicare.

For example, a physician would include a quality code to indicate that a diabetic beneficiary’s most recent LDL-C was 100-129 mg/dL when billing for the office visit during which the level was reviewed/discussed. You only need to report the results of the most recent LDL-C once during the 12-month reporting period.

While selecting from 153 quality measures can be daunting, you can narrow the options by focusing on a particular clinical condition. For example, the first three measures on the list of 153 pertain to treatment of diabetic patients. You can select this option even if you have yet to start reporting in 2009. Many of the 153 individual measures most relevant to internists—including those for diabetes, coronary artery disease, and some geriatrics measures—only require one eligible encounter report during the 12-month reporting period.

Disease/condition-specific measures groups. CMS has identified seven disease/condition-specific measures groups for 2009, up from four in 2008. Internists are most likely to use the diabetes mellitus measures group, which comprises six individual quality measures, and the preventive care group, comprising nine individual measures.

CMS requires physicians to report an agency-maintained “G” code to indicate the measures group option. There is a different G code for each of the seven measures groups. For each eligible patient encounter, report the relevant quality procedure code for each individual measure in the group on the claim form. You only need to report the G group-indicator-code on the first patient for whom you report the group measure (but you will not be penalized if you include it on claims for subsequent patients).

There are two ways to earn a successful reporting bonus for the full calendar year reporting period:

  • report the quality codes for each of the relevant individual measures in the group for 30 consecutive eligible patients, or
  • report on the measures group for 80% or more of all of your eligible patients.

Meeting the 80% threshold will likely require reporting on more patients over a longer period of time than the 30-consecutive-patient option, but it provides leeway to miss reporting on an eligible patient.

You can also earn a bonus for the July 1 through Dec. 31 reporting period by reporting the measures group on at least 80% of eligible patients during that period, with a minimum of 15 patients.

Reporting data through a registry. Some physicians maintain databases on certain patients or procedures in order to improve patient tracking, management and quality of care. CMS allows physicians to earn a PQRI bonus based on the transmission of data from these clinical registries to CMS in 2009. Registries will be able to report quality data submitted by physicians for both the individual quality measure and measures group reporting options and for the full 12-month and six-month (starting July) 2009 reporting periods.

The agency selected 32 registries for participation in PQRI 2008, and is expected to add more in 2009. Some registries provide physician-use opportunities specifically aimed at qualifying for a PQRI bonus.

Q: It’s nice to have different reporting options, but has CMS done anything to fix the numerous problems that have frustrated those who have participated in the past?

A: While the PQRI program remains far from perfect, CMS has taken steps to address the problems identified in its assessment of the 2007 program and from concerns expressed directly by physicians.

CMS refined its analytical method that determines successful reporting so that any diagnosis code on the claim is matched to each procedure and quality measure code on the claim. You previously had to “point” the diagnosis code that made it an eligible encounter to the quality measure code(s). The agency is “re-running” its analysis of 2007 reporting and expects to inform physicians who initially did not qualify that they, in fact, did successfully report. CMS will pay bonuses that result from this retrospective review when it pays the 2008 bonuses this fall.

Widespread consistent use of the NPI, which created problems beyond its May 2007 implementation date, will improve the attribution of services to individual physicians, making their reporting and bonus payments more accurate.

Q: It still seems like a lot of work for a 2% bonus. Should I bother to participate?

A: Integrating the steps your practice needs to take into your normal workflow is key to realizing a bonus payment that exceeds your cost of participation. In addition, recent improvements to the program will make it easier and thus, less costly, to obtain your reporting and performance score feedback report. Participating also keeps you in step with current thinking by policymakers that pay-for-reporting/pay-for-performance should be part of the overall effort to get value from Medicare spending.

Further, finding a cost-effective way to earn the 2% bonus available through the separate Medicare e-prescribing incentive program, which took effect Jan. 1, would enhance your bonus revenue opportunities. ACP maintains information and guidance on the Medicare e-prescribing incentive program online.

Q: Where can I find additional information that will help me to participate in PQRI?

A: ACP maintains a PQRI Web site. CMS maintains comprehensive information online.

Brett Baker is ACP’s Director of Regulatory and Insurer Affairs.

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