a physiatrist’s guide to the centers for medicare and medicaid services’ physician quality...
TRANSCRIPT
A Physiatrist’s Guide to the Centers for Medicare and Medicaid Services’ Physician Quality Reporting Initiative
This presentation was current at the time it was published or uploaded onto the Web. Medicare policy frequently changes so links to the source documents have been provided within the document for your reference.
The Academy makes no guarantee the information is error-free and will bear no responsibility or liability for the results of the use of this guide. This presentation is a general guide that explains certain aspects of the PQRI program, but is not a legal document.
The aforementioned information is copied from CMS’ website
PQRI Introduction
The intent of this presentation is to assist physiatrists who elect to participate in the Centers for Medicare and Medicaid Services’ (CMS) Physician Quality Reporting Initiative (PQRI). Although the Academy has made reasonable attempts to assure the accuracy of the information, the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services.
The aforementioned information is copied from CMS’ Website
PQRI Introduction
PRQI Introduction
PQRI program is part of the Tax Relief and Healthcare Act (TRHCA) enacted by Congress in December 2006. Originally, the program was called the Physician Voluntary Reporting Program (PVRP) in which physicians voluntarily submitted data on 16 evidence-based quality measures in 2006.
PQRI Introduction
In March 2007, CMS transitioned from the PVRP program to the PQRI program and published 74 quality measures for health care professional to utilize for 2007. Physicians and other eligible health care professionals have an opportunity to receive a bonus equal to 1.5% of allowable Part B charges for all covered professional services through submission of claims data.
PQRI Introduction
PQRI reporting will focus on quality of care o Evidence-based measures developed through a
collaborative process o Potential to receive financial incentive by
reporting data o Improvement in care through measuremento Reporting is the first step towards pay-for-
performance
The aforementioned information is copied from CMS’ website
PQRI Introduction
Physicians, physical therapists and clinical social workers are just a few of the eligible health care professionals that can elect to participate in the PQRI program
To view the complete list of eligible health care professionals, please click on the following link: www.cms.hhs.gov/PQRI
PQRI Introduction
Eligible health care providers can participate in the PQRI program by submitting performance measurement data on three or more of the 2007 PQRI measures. Eligible health care providers must select measures that are most applicable to their patient populations and report 80% of the time on these measures to potentially receive a bonus.
PQRI Introduction
The 2007 PQRI measures are posted on CMS’ website along with their specifications. The measure specifications may be updated and reposted prior to the July 1, 2007 start date to expand applicability of the measure. To view the measures please visit CMS’ website: www.cms.hhs.gov/PQRI.
PQRI Introduction
Academy members have reviewed the 74 PQRI measures and identified measures that are applicable to some physiatrists. Within the PQRI program, the osteoporosis and stroke measures appear to be most appropriate for some physiatrists to utilize.
PQRI Introduction
The reporting period for the program is for the dates of service between July 1 and December 31, 2007
Reporting thresholds are set by statute. If there are no more than 3 measures that apply then each measure must be reported for at least 80% of the cases in which a measure was reportable
The aforementioned information is copied from CMS’ website
PQRI Introduction
If 4 or more measures apply:o At least 3 measures must be reported for at least
80% of the cases in which the measures was reportable
If there are less than 3 measures that apply:o CMS is developing a validation protocol to ensure
that other measures were not appropriate for reporting
The aforementioned information is copied from CMS’ website
PQRI Introduction
Validation o The statute requires CMS to use sampling or other means
to validate whether quality measures applicable to the service have been reported
o The validation plan will be posted on CMS’ website prior to July 1, 2007 www.cms.hhs.gov/PQRI
Appeals o The statute excludes PQRI related determinations from
formal administrative or judicial review
The aforementioned information is copied from CMS’ website
PQRI Introduction
Bonus payment calculation is set by statute Participating eligible professionals who successfully
report may earn a 1.5% bonus, subject to a cap The cap is meant to encourage more instances of
measure reporting – the more instances of reporting make the cap less likely to apply
Bonus payments will be made to the holder of Taxpayer Identification Number (TIN) in a lump sum in mid-2008
The aforementioned information is copied from CMS’ website
Cap calculation =1. Individual’s instances of reporting data
X2. 300%
X3. National average per measure payment amount
o National average per measure payment amount = National total charges associated with quality measures / National total instances of reporting
The aforementioned information is copied from CMS’ website
PQRI Introduction
PQRI Overview
Integration of PQRI quality data reporting into your care of delivery processes
1. Select measures most appropriate for your practice
2. Define roles of those involved in submission of data to ensure successful reporting
3. Modify workflows and billing systems to increase efficiency of reporting
The aforementioned information is copied from CMS’ website
PQRI Overview
Select measures that are most applicable for the services you provide to patients and consider your quality improvement goals for 2007. The Academy has aligned PQRI measures with various practice areas for physiatrists. Please review the specifications of the measures to determine if a particular measure is appropriate for your practice.
PQRI Overview
Orthopedic Rehabilitation 4) Screening for Future Fall Risk 24) Osteoporosis: Communication with Physician Managing
Ongoing Care39) Screening or Therapy for Osteoporosis for Women Aged 65
Years and Older41) Osteoporosis: Pharmacological Therapy 42) Osteoporosis: Counseling for Vitamin D, Calcium Intake, and
Exercise
The aforementioned information is copied from CMS’ website
PQRI Overview
Stroke/Neurological Rehabilitation 4) Screening for Future Fall Risk 31) Stroke and Stroke Rehabilitation: Deep Vein Thrombosis
(DVT) for Ischemic Stroke or Intracranial Hemorrhage 32) Stroke and Stroke Rehabilitation: Discharge on Antiplatelet
Therapy 33) Stroke and Stroke Rehabilitation: Anticoagulant Therapy
Prescribed for Atrial Fibrillation at Discharge 34) Stroke and Stroke Rehabilitation: Tissue Plasma Activator (t-
PA) Considered
The aforementioned information is copied from CMS’ website
PQRI Overview
Stroke/Neurological Rehabilitation Cont. 35) Stroke and Stroke Rehabilitation: Screening for Dysphagia 36) Stroke and Stroke Rehabilitation: Consideration of
Rehabilitation
Spine Medicine: Non-Interventional 4) Screening for Future Fall Risk 24) Osteoporosis: Communication with the Physician Managing
Ongoing Care Post Fracture
The aforementioned information is copied from CMS’ website
PQRI Overview
Spine Medicine - Interventional 24) Osteoporosis: Communication with the Physician
Managing Ongoing Care Brain Injury Rehabilitation 4) Screening for Future Fall Risk 31) Stroke and Stroke Rehabilitation: Deep Vein
Thrombosis (DVT) for Ischemic Stroke or Intracranial Hemorrhage
The aforementioned information is copied from CMS’ website
PQRI Overview
Spinal Cord Medicine 4) Screening for Future Fall Risk24) Osteoporosis: Communication with the Physician
Managing Ongoing Care Post Fracture
Occupational Rehabilitation: 24) Osteoporosis: Communication with the Physician
Managing Ongoing Care Post Fracture
The aforementioned information is copied from CMS’ website
PQRI Overview
Geriatrics 4) Screening for Future Fall Risk 24) Osteoporosis: Communication with the Physician Managing
Ongoing Care Post Facture 39) Screening or Therapy for Osteoporosis for Women Aged 65
Years and Older 41) Osteoporosis: Pharmacological Therapy 42) Osteoporosis: Counseling for Vitamin D, Calcium Intake, and
Exercise 47) Advance Care Plan
The aforementioned information is copied from CMS’ website
PQRI Overview
Disability/Impairment 4) Screening for Future Fall Risks
Prosthetics & Orthotics 4) Screening for Future Fall Risks
Rheumatoid Arthritis 24) Osteoporosis: Communication with the Physician Managing
Ongoing Care Post Fracture
The aforementioned information is copied from CMS’ website
PQRI Overview
Reporting Measure Data
Determine the process by which you will report data once you have identified appropriate measures for the patient population that you serve. Assign responsibility and educate each team member to accurately and efficiently carry out the reporting process.
The aforementioned information is copied from CMS’ website
PQRI Overview
Reporting Measure Data
Discuss system capabilities with practice management software vendors and third-party billing vendors/clearing houses to determine what system changes may be required to capture quality data codes. CMS encourages participants to undertake this process prior to July 1, 2007.
The aforementioned information is copied from CMS’ website
PQRI Overview
Reporting Measure Data o CPT Category II codes may be reported on paper-based
1500 or electronic 873-P claims o The CPT Category II code, which supplies the numerator,
must be reported on the same claim form as the payment ICD-9 and CPT Category I codes, which supply the denominator
o The individual National Provider Identifier (NPI) of the professional must be properly used on the claim.
o Please click on the following link to learn additional information on obtaining an NPI number:
http://www.cms.hhs.gov/NationalProvIdentStand The aforementioned information is copied from CMS’ website
PQRI Overview
Reporting Measure Data o Multiple CPT Category II codes can be reported on the
same claim, as long as the corresponding denominator codes are on the claim
o The individual NPI of the participating professional must be properly used on the claim
o Line item charges should be $0.00. If the system does not allow $0.00, CMS recommends using a small amount like $0.01. Entire claims with a zero charge will be rejected by CMS
The aforementioned information is copied from CMS’ website
PQRI Overview
The National Claims History (NCH) file must receive claims by February 29, 2008 to be included in the analysis
Analysis will be performed by individual NPI under each TIN
Ensure that your carrier/Medicare Administrative Contractor (MAC) has the accurate TIN for your claims
The aforementioned information is copied from CMS’ website
PQRI Overview
Confidential Feedback Reports o 2007 PQRI quality data will not be publicly
reportedo Reports will be available at or near the time of the
bonus payment in 2008o Reports are expected to include reporting and
performance rates by NPI for each TIN
The aforementioned information is copied from CMS’ website
PQRI Program
CMS intends to post additional guidelines for reporting data on its website prior to July 1, 2007. www.cms.hhs.gov/PQRI
Successful Reporting Scenario I
Mr. Jones is preparing to be discharged from aninpatient rehabilitation
stay after having a stroke. Dr. Smith reviews his
chart and discharges himon antiplatelet therapy
Situation 1 Dr. Smith prescribes
antiplatelet therapy forMr. Jones
CPT II code 4073F
Situation 2Dr. Smith documents
that antiplatelet therapy is contraindicated for Mr.
Jones because he has a bleeding disorder
CPT II code 4073F-1P modifier
Situation 3There is no documentation
that Dr. Smith or other eligible professionals addressed antiplatelet therapy for Mr. Jones. CPT II code 4073F-
8P modifier
Prospective Payment System
When submitting data for the PQRI program, physiatrists MUST utilize ICD-9 codes that are included in BOTH the PQRI program and CMS’ Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS). For example, stroke is part of the IRF PPS and the PQRI program. The following page provides ICD-9 codes for stroke that are included in both programs.
Perspective Payment System
The following ICD-9 codes are part of the IRF PPS and included in the PQRI stroke measures
431, 433.01,433.11,433.21,433.31,
433.81,433.91,434.01,434.11,434.91 When submitting data on inpatient diagnoses for the
PQRI program, physiatrists MUST utilize ICD-9 codes included in the IRF PPS to be accounted for in both programs.
Successful Reporting Scenario 2
Mrs. Jones, a 69 year old female, presents for an
office visit with Dr. Smith. Mrs. Jones appears to have
trouble with her balance
Situation 1Dr. Smith screens Mrs.Jones for future fall riskCPT II code 1100F or
1101F
Situation 2Mrs. Jones is confused and unable to provide Dr. Smith
information on any recent falls
CPT II code 1100F- 1P modifier
Situation 3There is no documentation
that Dr. Smith or other eligible professionals
assessed Mrs. Jones for risk of falls
CPT II code 1100F - 8P modifier
2008 PQRI Program
Statutory requirements for 2008 measures o Adopted or endorsed measures by a consensus
organization, such as the AQA Alliance or the National Quality Forum
o Used a consensus-based process for development
o Include structural measures, such as the use of electronic health records or electronic prescribing technology
The aforementioned information is copied from CMS’ website
2008 PQRI Program
Registry-Based Reporting o CMS is working towards registry-based reporting
for 2008o Standardized specifications for centralization
reporting could reduce the burden of reporting for participants and CMS
The aforementioned information is copied from CMS’ website
Additional Information
CMS frequently posts new information on the PQRI program. Please click on the following website to learn the latest information.
www.cms.hhs.gov/PQRI