pqri and category ii codespqri and category ii codes physicians quality reporting initiative • on...

© Copyright 2008 American Health Information Management Association. All rights reserved.

PQRI and Category II Codes

Practical Tools for Seminar Learning

Disclaimer

AHIMA • http://campus.ahima.org

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The American Health Information Management Association makes no representation or guarantee with respect to the contents herein and specifically disclaims any implied guarantee of suitability for any specific purpose. AHIMA has no liability or responsibility to any person or entity with respect to any loss or damage caused by the use of this audio seminar, including but not limited to any loss of revenue, interruption of service, loss of business, or indirect damages resulting from the use of this program. AHIMA makes no guarantee that the use of this program will prevent differences of opinion or disputes with Medicare or other third party payers as to the amount that will be paid to providers of service.

How to earn one (1) CEU for participation

To earn one (1) continuing education unit, each participant must do the following: Step 1: Listen to the seminar, via Webcast link or audio CD. Step 2: Complete the assessment quiz contained in this resource book.

Use the included answer key. Do not return the quiz to AHIMA. Save it for your records.

Step 3: EACH LISTENER must visit

http://campus.ahima.org/audio/fastfactsresources.html and complete the sign-in form and the seminar evaluation.

Step 4: After you complete the evaluation, you will receive your CE certificate which

you should print for your records. The certificate must be retained by each participant as a record of their participation, along with a copy of their completed quiz.

Faculty


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Shelley C. Safian, CCS-P, CPC-H, CHA

Shelley C. Safian, Chair of the Allied Health Department at Herzing College, is also the Senior Assistant Professor for the Medical Billing and Insurance Coding program. She is currently teaching coding and medical office administration at both Herzing College – Winter Park (Orlando), Florida as well as Herzing College Online.

Safian is a Certified Coding Specialist-Physician-based from the American Health Information Management Association (AHIMA) and a Certified Professional Coder- Hospital from the American Academy of Professional Coders (AAPC). She also holds a National Certified Insurance Coding Specialist (NCICS) designation, as well as that of Certified HIPAA Administrator (CHA).

Safian completed her Graduate Certificate in Health Care Management in June 2005 at Keller Graduate School of Management. The University of Phoenix awarded her Master of Arts/Organizational Management degree in 2002.

The Florida Association of Post-secondary Schools and Colleges (FAPSC) named Safian Faculty Member of the Year 2006–2007. Herzing College, Winter Park honored Safian by naming her 2007 Teacher of the Year, and she was awarded the Faculty Scholarship Award—First Runner Up for the Herzing College System for 2006.

Safian is a volunteer AHIMA Mentor, working with health information management students from all across the country, and sits on the AHIMA Classification Practice Council. She attends local chapter meetings of the Central Florida Health Information Management Association (CFHIMA) whenever her schedule permits, and encourages her students to join her at the Florida Health Information Management Association (FHIMA) Annual Convention every year.

McGraw-Hill Higher Education published Insurance Coding & Electronic Claims for the Medical Office by Safian in July, 2005. Her second, third, and fourth books, The Complete Procedure Coding Book, The Complete Diagnosis Coding Book, and You Code It! A Case Studies Workbook were published simultaneously in February, 2008.

Table of Contents


Disclaimer ..................................................................................................................... i How to earn one (1) CEU for participation ......................................................................... i Faculty ......................................................................................................................... ii PQRI and Category II Codes ........................................................................................... 1 Physicians Quality Reporting Initiative .............................................................................. 1 PQRI Effective Dates ...................................................................................................... 2 PQRI Eligible Professionals ........................................................................................... 2-5 PQRI Performance Measures ........................................................................................... 6 Category II Codes .......................................................................................................... 6 PQRI Bonus Payments .................................................................................................... 7 More Details: PQRI Performance Measures ............................................................................ 8-9 PQRI Reporting ............................................................................................ 10-15 PQRI Incentive Payments .............................................................................. 16-17 Resource/Reference List ................................................................................................ 17 AHIMA Audio Seminars .................................................................................................. 18 About assessment quiz .................................................................................................. 18 Thank you for attending (with link for evaluation survey) ................................................. 19 Appendix .................................................................................................................. 20 Web Resource List PQRI Participation Decision Tree PQRI Reporting Options Quick Reference Chart Assessment Quiz CE Certificate and Sign-in Instructions Quiz Answer Key


AHIMA • http://campus.ahima.org 1

Notes/Comments

PQRI and Category II codes

Physicians Quality Reporting Initiative• On December 20, 2006 the President

signed the Tax Relief and Health Care Act of 2006 (TRHCA).

• Title I, Section 101 authorizes CMS to create a physician quality reporting system, the Physician Quality Reporting Initiative (PQRI).

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Physicians Quality Reporting Initiative

• PQRI establishes a financial

incentive for eligible professionals

to participate in a voluntary

quality reporting program.

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Notes/Comments

PQRI Effective Dates

• PQRI began July 2007.• The TRHCA requires that the final set

of PQRI measures for each year be published in the Federal Register by November 15th of the prior year identifying the final list of the next year’s PQRI measures

• For example: 2008 PQRI measures were published prior to November 15, 2007.

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PQRI Eligible Professionals

TRHCA section 101 defines "eligible professional" as the following:

• Medicare physician, as defined in Social Security Act (SSA) section 1861(r)

• Practitioners described in SSA section 1842 (b)(18)(C)

• Therapists

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Notes/Comments


Examples of Medicare Physicians:• Doctor of Medicine (MD)• Doctor of Osteopathy (DO)• Doctor of Podiatric Medicine (DPM)• Doctor of Optometry (OD)• Doctor of Oral Surgery (DDS)• Doctor of Dental Medicine (DDM)• Chiropractor

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• Practitioners described in SSA section 1842(b)(18)(C)

• Therapists

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Notes/Comments


Examples of Practitioners: • Physician Assistant• Nurse Practitioner• Clinical Nurse Specialist• Certified Registered Nurse Anesthetist• Certified Nurse Midwife• Clinical Social Worker• Clinical Psychologist• Registered Dietician• Nutrition Professional

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• Practitioners described in SSA section 1842 (b)(18)(C)

• Therapists

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Notes/Comments


Examples of Therapists:• Physical Therapist• Occupational Therapist• Qualified Speech-Language Therapist

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• Eligible professionals should familiarize themselves and their office staff with the PQRI measures that appear to apply to their patients.

• Measures/Codes page to access the measures list are updated each year on the CMS website.

• Measures are also listed in the CPT book, Appendix H.

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Notes/Comments

PQRI Performance Measures

Example from Appendix H: Otitis Media with Effusion (OME)1

• Measure #6: Otitis Media with Effusion (OME)Antihistamines or decongestants – Avoidance of inappropriate use

• Whether or not the parent/caregiver of the patient aged 2 monthsthrough 12 years with a diagnosis of OME was not prescribed or recommended to receive antihistamines or decongestants

• Numerator: Patients who were not prescribed or recommended to receive antihistamines or decongestants

• Denominator: All patients aged 2 months through 12 years with a diagnosis of OME

• Category II codes: 4133F Antihistamines or decongestants prescribed or recommended 4134F Antihistamines or decongestants neither prescribed nor

recommended

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Category II codes

• Category II codes [HCPCS Level I, Category II] are used to report services

• Category II codes must be reported on the CMS-1500 claim form

• No more than $1.01 may be charged for a category II code and only when the physician’s claim system will not accept $0.00

• Category II codes are 4 numbers followed by the letter F [e.g. 2000F]

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Notes/Comments

PQRI Bonus Payments

To meet the requirements of the program and receive the bonus payment:

Physicians with fewer than 3 quality measures applicable to services provided by an eligible professional:

Each measure must be reported in at least 80% of the cases in which the measure is reportable.

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PQRI Bonus Payments

To meet the requirements of the program and receive the bonus payment:

Physicians with 4 or more quality measures applicable to services provided by an eligible professional:

Each measure must be reported in at least 80% of the cases in at least 3 of the measures that are reported.

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Notes/Comments

PQRI and Category II codes

More details…

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• The performance measures are updated each year

For example:

2008 PQRI consists of • 119 quality measures, including • 2 structural measures

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Notes/Comments


• A quality measure reports that a healthcare professional provided, or attempted to provide, a specific service

For example:

Whether or not patient was assessed for influenza immunization status 1030F Influenza immunizations status assessed

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• A structural measure reports that a healthcare professional uses electronic health records and the other electronic prescribing.

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Notes/Comments

PQRI Reporting

• Category II Codes• Report a specific service provided or attempted

Example:

2000F Blood pressure measured

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PQRI Reporting

•G Codes• In some cases, G codes (from HCPCS Level II code set) may be accurate to report PQRI measures

Example:

G8485 (Clinician intends to report the Diabetes measure) for intent to report the Diabetes measure group;

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Notes/Comments

PQRI Reporting

• Composite Codes• A single Category II code that reports multiple services provided, or attempted

• Only report when ALL components have been met

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PQRI Reporting

•Composite CodesExample:

• 0001F Heart failure assessed• Blood pressure measured• Level of activity measured• Clinical symptoms of volume overload

assessed • Weight recorded• Clinical signs of volume overload

assessed22



Notes/Comments

PQRI Reporting

• Measures Groups• Subsets of PQRI measures that have a common focus

• Diabetes Mellitus• End Stage Renal Disease (ESRD)• Chronic Kidney Disease (CKD)• Preventive Care

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PQRI Reporting

• Each measures group contains at least four PQRI measures

Example:

ESRD Measures Group includesMeasures #78, 79, 80, and 81

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Notes/Comments

PQRI Reporting

•Category II Modifiers• May only be used with category II codes

• Identify service attempted but not performed

• Restrictions on the use of modifiers may be shown in Appendix H

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PQRI Reporting

• 1P – Performance Measure Exclusion Modifier due to Medical Reasons

• 2P – Performance Measure Exclusion Modifier due to Patient Reasons

• 3P – Performance Measure Exclusion Modifier due to System Reasons

• 8P – Performance Measure Action Not Performed, reason NOS

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Notes/Comments

PQRI Reporting

•Reporting Options• CMS-1500 claim form (or 837 Electronic Claims SV1 Professional Service)

• Registry-based submission

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PQRI Reporting

• CMS-1500 Claim Form• Report Category II codes AFTER all other CPT (category I) and HCPCS Level II codes reporting reimbursable service(s)

• Amount charged must be $1.01 or less

• Code must be linked to a relevant Dx code (Field 24E)

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Notes/Comments

PQRI Reporting

• Remittance Advice Notices• When Category II code(s) are reported on

CMS-1500, Remark Code [N365] will show with a message…

• “This procedure code is not payable. It is for reporting/information purposes only.”

• Message confirms that PQRI reporting was processed

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PQRI Reporting

•Registry-based Reporting• Registries must meet certain technical and other requirements specified by CMS

• Registry-based submissions will begin after the completion of the registry testing process

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Notes/Comments

PQRI Incentive Payments

•Bonus Payments• Eligible professionals who satisfactorily report 1 – 3 PQRI measures through claims at lest 80% during the year

• Can earn 1.5% of allowed charges for services furnished during that reporting period

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• The analysis of satisfactory reporting will be performed at the individual eligible professional level using individual-level NPI.

• Incentives earned by individual professionals will paid to the Taxpayer Identification Number (TIN) under which his or her claims were submitted, aggregating individual incentives earned by members of groups that bill under one TIN.

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Notes/Comments


• CMS provides confidential feedback reports after the end of the PQRI reporting period.

• Reports will be based on the PQRI quality data reported by the participating physicians and other EPs for services provided during the reporting period.

• The participant feedback reports are expected to contain reporting and performance information at the individual-NPI level and aggregated at the TIN level.

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Resource/Reference List

• Centers for Medicare and Medicaid Serviceswww.cms.hhs.gov/PQRI

• Establishment of alternative reporting periods and criteria for the 2008 PQRI — see CR 6104, located at:www.cms.hhs.gov/Transmittals/downloads/R355OTN.pdf

• Federal Registerwww.gpoaccess.gov/fr/index/html

34



Notes/Comments

AHIMA Audio Seminars

Visit our Web site http://campus.AHIMA.orgfor updated information on the current seminar schedule. While online, you can also register for live seminars or order CDs and Webcasts of past seminars.

© 2008 American Health Information Management Association

Assessment

To access the assessment quiz that follows this seminar, download the seminar’s resource book at

http://campus.ahima.org/audio/fastfactsresources.html

Your sign-in form and certificate of completion are also found in the resource book.

NOTE: This slide is referring to THIS resource book.

To take the assessment quiz, turn to the end of this book.



Notes/Comments

Thank you for attending!

Please visit the AHIMA Audio Seminars Web site to complete your evaluation form online at:

http://campus.ahima.org/audio/fastfactsresources.html

Appendix


Web Resource List PQRI Participation Decision Tree PQRI Reporting Options Quick Reference Chart Assessment Quiz CE Certificate and Sign-in Instructions Quiz Answer Key

Appendix


Web Resource List Centers for Medicare and Medicaid Services www.cms.hhs.gov/PQRI

Establishment of alternative reporting periods and criteria for the 2008 PQRI — see CR 6104, located at: www.cms.hhs.gov/Transmittals/downloads/R355OTN.pdf

Federal Register www.gpoaccess.gov/fr/index/html

Physician Quality Reporting Initiative (PQRI) Participation Decision Tree

I WANT TO PARTICIPATE IN 2008 PQRIFOR INCENTIVE PAYMENT

(Select Reporting Method)

REGISTRY REPORTING

< 3 MEASURES APPLY

3 OR MORE MEASURES APPLY

ONLY OPTION IS TO REPORT CLAIMS FOR

12-MONTH REPORTING PERIOD

1/1/08-12/31/08

REPORT EACH MEASURE 80% OF APPLICABLE

PATIENTS REPORT 80% OF ELIGIBLE PATIENTS FOR A MEASURES GROUP THE FULL 6

MONTHS

REPORT 80% OF APPLICABLE PATIENTS

ON AT LEAST 3 MEASURES

REPORT 100% OF15 CONSECUTIVE

ELIGIBLE PATIENTS ANYTIME WITHIN 6

MONTHS

CHOOSE TO REPORT ON ≥ 3 MEASURES

FOR

12 MONTHS

1/1/08-12/31/08

CHOOSE TO REPORT MEASURES GROUP

FOR

6 MONTHS

7/1/08-12/31/08

Subject to Measure-Applicability Validation (MAV)

CHOOSE TO SUBMIT DATA ON 80% OF

ELIGIBLE PATIENTS ON AT LEAST 3

MEASURES

CHOOSE TO SUBMIT DATA ON

MEASURES GROUP

CHOOSE TO REPORT

12 MONTHS

1/1/08-12/31/08

CHOOSE TO REPORT

6 MONTHS

7/1/08-12/31/08

SUBMIT DATA ON 100% OF 30

CONSECUTIVE ELIGIBLE

PATIENTS WITHIN 12 MONTHS

SUBMIT DATA ON 80% OF

APPLICABLE PATIENTS FOR

THE MEASURES GROUP

SUBMIT DATA ON 100% OF 15

CONSECUTIVEELIGIBLE

PATIENTS WITHIN 6 MONTHS

SUBMIT DATA ON 80% OF ELIGIBLE

PATIENTS FOR A MEASURES

GROUP

CLAIMS-BASED REPORTING

SUBMIT

12 MONTHS

1/1/08-12/31/08

SUBMIT

6 MONTHS

7/1/08-12/31/08


(Select Reporting Method)


1/1/08-12/31/08

CLAIMS

80% OF ELIGIBLE

PATIENTS ON AT LEAST 3

MEASURES OR ON EACH

MEASURE IF < 3 MEASURES

REGISTRY

80% OF ELIGIBLE

PATIENTS FOR THE FULL 6

MONTHS

100% OF15

CONSECUTIVE ELIGIBLE PATIENTS ANYTIME WITHIN 6 MONTHS

80% OF ELIGIBLE

PATIENTS ON AT LEAST 3 MEASURES


(Select Reporting Period)

REGISTRY

80% OF ELIGIBLE PATIENTS

ON AT LEAST 3

MEASURES

MEASURES GROUPS

100% OF 30 CONSECUTIVE

ELIGIBLE PATIENTS

ANYTIME WITHIN 12 MONTHS

80% OF ELIGIBLE

PATIENTS FOR THE FULL 12

MONTHS


7/1/08-12/31/08

CLAIMS

100% of 15 CONSECUTIVE

ELIGIBLE PATIENTS FOR

THE MEASURES GROUP

ANYTIME WITHIN 6 MONTHS

80% OF ELIGIBLE

PATIENTS IN MEASURES

GROUP

MEASURES GROUPS

Medicare Physician Quality Reporting Initiative May 2008

2008 PQRI Reporting Options Quick Reference Chart

http://www.cms.hhs.gov/PQRI

Claims-based SubmissionJan 1, 2008 - Dec 31, 2008 Reporting Period Jul 1, 2008 - Dec 31, 2008 Reporting Period

Individual Measures1-3 measures

80% of applicable Medicare cases

Include appropriate quality data code(s) (CPT II or G-code) on all applicable claims.

Measures GroupsAll measures in one Measures Group

15 consecutive Medicare patientsOR


Include appropriate Measures Group G-code on the initial claim AND the appropriate quality

data code(s) (CPT II or G-code) for each measure in the Measures Group on all

applicable claims, including the initial claim.

Registry-based SubmissionJan 1, 2008 - Dec 31, 2008 Reporting Period

Individual Measures3 measures



30 consecutive patientsOR


Consecutive patients must include Medicare - may include some non-Medicare

Jul 1, 2008 - Dec 31, 2008 Reporting Period

Individual Measures 3 measures



15 consecutive patientsOR

80% applicable Medicare cases

Consecutive patients must include Medicare - may include some non-Medicare

Use of a G-code is not required for registry-based submission.

This quick reference information was prepared as a service to the public and is not intended to grant rights or impose obligations. This quick reference information may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the

specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.

PQRI Quick Reference Chart ICN: 900843

Assessment Quiz – PQRI and Category II Codes

AHIMA • http://campus.ahima.org ANSWERS to this quiz are found on the last page of the seminar resource book, Practical Tools for Seminar Learning.

To earn continuing education credit of one (1) AHIMA CEU, Fast Facts Audio Seminar listeners must also complete this 10-question quiz. This CE credit is for attending the audio seminar AND completing this quiz. Please keep a copy of the completed quiz with your CE certificate. Do not send a copy to AHIMA.

1. PQRI stands for:

a. Patient Quality Response Indicators b. Provider Query Requirements and Initiatives c. Physician Quality Reporting Initiative d. Procedure Quality Registration Itemization

2. An “eligible professional” may be any of these

except: a. Doctor of Optometry b. Physical Therapist c. Clinical Social Worker d. Doctor of Oriental Medicine

3. An example of a Category II code is:

a. 1111F b. 1111T c. F1111 d. 12345

4. The physician wanted to take the elderly

woman’s blood pressure. However, she was suffering from shingles and could not physically tolerate the cuff. How should this performance measure be reported? a. 0001F b. 2001F c. 2010F-1P d. 2000F-2P

5. PQRI can be reported

a. CMS-1450 claim form b. CMS-1500 claim form c. Registry-based reporting d. B and C only

6. Bonus payments may be earned equal to:

a. 15% of allowed charges b. 1.5% of Medicare payments c. 1.5% of Medicare allowed charges d. 13% of the practice’s gross annual revenue

7. Remittance Advice code N365 means that the

PQRI report has been: a. Denied b. Processed c. Rejected d. Incorrect

8. Bonus payments are calculated for those EPs

achieving satisfactory reporting levels, measured by the provider a. TIN b. NPI c. CPT d. A and B only

9. The physician documented that his eligible

patient was dehydrated. Report this with the following category II code: a. 2031F b. 2030F c. 2029F-1P d. 2031F-8P

10. The patient stated he was having trouble with his

eyes, so the physician wanted to perform a visual functional status assessment. The equipment was not available and the assessment could not be completed. Report this with category II code: a. 1055F b. 1055F-3P c. 2027F-1P d. 2026F

Do not send a copy of completed quizzes to AHIMA. Please keep them with your CE certificate, for your records. Be sure to sign-in and complete your evaluation form, to receive your certificate, at

http://campus.ahima.org/audio/fastfactsresources.html.

To receive your

CE Certificate

visit http://campus.ahima.org/audio/fastfactsresources.html

click on the link to

“Sign In and Complete Online Evaluation” listed for this seminar.

You will be automatically linked to the

CE certificate for this seminar after completing the evaluation.

Each participant expecting to receive continuing education credit must complete the online evaluation and sign-in information,

in order to view and print the CE certificate.


Quiz Answer Key Fast Facts Audio Seminar: PQRI and Category II Codes 1: c; 2:d; 3: a; 4: d; 5: d; 6: c; 7: b; 8: d; 9: a; 10: b Do not send a copy of your completed Fast Facts Audio Seminar quiz to AHIMA. Please keep it with your CE certificate, for your records.

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