2008 Medicare PQRI

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Centers for Medicare & Medicaid Services

2008 Physician Quality Reporting Initiative (PQRI)

December 19, 2007

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Overview

• PQRI Introduction: Information about PQRI• PQRI Tools: Implementing PQRI• PQRI Principles: Understanding the

Measures• PQRI Coding: Examples of Measures• PQRI 2008: Additional Considerations• PQRI Readiness: Ensuring Success

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PQRI Introduction: Value-Based Purchasing

• Value-based purchasing is a key mechanism for transforming Medicare from a passive payer to an active purchaser.– Current Medicare Physician Fee Schedule is

based on quantity and resources consumed, NOT quality or value of services.

• Value = Quality / Cost– Incentives can encourage higher quality and

avoidance of unnecessary costs to enhance the value of care.

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PQRI Introduction:The Statute

• Tax Relief and Healthcare Act (TRHCA) Section 101 Implementation– Eligible Professionals– Quality Measures– Form and Manner of Reporting– Determination of Successful Reporting– Bonus Payment– Validation– Appeals– Confidential Feedback Reports– 2008 Considerations– Outreach and Education

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PQRI Introduction: Focus on Quality

• PQRI reporting will focus attention on quality of care.– Foundation is evidence-based measures

developed by professionals– Measurement enables improvements in care– Reporting is the first step toward pay for

performance

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PRQI Introduction:Building a Platform

Visit Documented in the Medical Record

Encounter Form Coding & Billing

Carrier/MAC

NCHNational Claims

History FileAnalysis Contractor

Bonus PaymentConfidential Report

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PQRI Introduction:Successful Reporting

• Determination of Successful Reporting– Reporting thresholds

• If there are no more than 3 measures that apply, each measure must be reported for at least 80% of the cases in which a measure was reportable

• If 4 or more measures apply, at least 3 measures must be reported for at least 80% of the cases in which the measure was reportable

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PQRI Introduction: The Bonus

• Bonus Payment– Participating eligible professionals who successfully report

may earn a 1.5% bonus, subject to cap• 1.5% bonus calculation based on total allowed charges

during the reporting period for professional services billed under the Physician Fee Schedule

• Claims must reach the National Claims History (NCH) file by February 29, 2008

– Bonus payments will be made in a lump sum in mid-2008 – Bonus payments will be made to the holder of record of the

Taxpayer Identification Number (TIN)– No beneficiary coinsurance

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PQRI Introduction:The Cap Calculation

• Bonus Payment– Cap may apply when relatively few instances of

quality measures are reported

– Cap calculation =1. (Individual’s instances of reporting quality data) X2. (300%) X3. (National average per measure payment amount)

National average per measure payment amount =(National charges associated with quality measures) /(National instances of reporting)

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Physician Quality Reporting Initiative (PQRI)

• Validation– TRHCA requires CMS to use sampling or other

means to validate whether quality measures applicable to the services have been reported

– Validation plan posted on website• Appeals

– Determinations are excluded from formal administrative or judicial review

– CMS will establish an informal inquiry process

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PQRI Introduction: Feedback Reports

• Confidential Feedback Reports– enable quality improvement at the

practice level– include reporting and performance

rates by NPI for each TIN.

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PQRI 2008:Additional Reporting Options

• Registry-based reporting– Use of a data system that collects PQRI measure data and

quality data codes for electronic submission to a CMS-designated clinical data warehouse using a CMS-specified record layout based on PQRI measure specifications

• Electronic health record (EHR)-based reporting– Specifications recently posted on the CMS website for the

electronic reporting of 5 measures

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Coding for Quality:PQRI Tools

ImplementingPQRI

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PQRI Tools: Where to Begin

• Gather information and educational materials from the PQRI web page: www.cms.hhs.gov/pqri on the CMS website.

• Gather information from other sources, such as your professional association, specialty society or the American Medical Association.

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PQRI Tools: The PQRI Website

• www.cms.hhs.gov/pqri– Overview– CMS Sponsored Calls– Statute/Regulations/Program Instructions– Eligible Professionals– Measures/Codes– Reporting– Analysis and Payment– Educational Resources

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PQRI Tools: MLN 5640: Coding and Reporting Principles

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PQRI Tools:The Measure List

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PQRI Tools: Coding for QualityA Handbook for PQRI Participation

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PQRI Tools:Check the Release Notes

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PQRI Tools: Coding for QualityA Handbook for PQRI Participation

• Selecting measures and preparing to report• PQRI coding and reporting principles for the

claims based submission of quality data codes• Sample clinical scenarios for each measure, listed

by clinical condition/topic, describes successful reporting (and performance where applicable)

• PQRI Glossary• 2007 PQRI Code Master• Sample implementation flow chart

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PQRI Tools: Coding for QualityA Handbook for PQRI Participation

• Clinical Conditions– Asthma– Cancer ( Breast, Colon,

CLL, etc)– Chest Pain– COPD– CAD– Depression– Diabetes– GERD

• Clinical Topics– Advance Care Planning– Screening for Fall Risk– Imaging– Medication

Reconciliation– Perioperative Care

Examples of Clinical Conditions/Topics

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PQRI Tools: Measure-specific Data Collection Worksheets

• Measure Specific– Measure Description– Worksheet– Coding Specifications

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Coding for Quality:PQRI Principles

Understanding the Measures

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PQRI 2008-Statutory Requirements

Statutory Requirements for 2008 Measures• Adopted or endorsed by a consensus organization, such

as the AQA Alliance or National Quality Forum (NQF)• Include measures that have been submitted by a

physician specialty• Used a consensus-based process for development• Include structural measures, such as the use of

electronic health records or electronic prescribing technology

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Understanding the Measures:Commonalities

• 119 unique measures associated with clinical conditions that are routinely represented on Medicare Fee-for-Service (FFS) claims – ICD-9-CM diagnosis codes – HCPCS codes

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PQRI 2008: 119 Measures

• Seven Categories of Measures– National Quality Forum-endorsed 2007 PQRI Quality Measures– AMA Physician Consortium for Performance Improvement developed

measures– Measures for non-physician eligible professionals developed by

Quality Insights of Pennsylvania– Structural measures related to EHRs and e-prescribing developed by

Quality Insights– Measures from the AQA Alliance starter set– Other NQF-endorsed measures not included in 2007 PQRI– Measures under development by the American Podiatric Medical

Association

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Understanding the Measures: Scope

• The measures address various aspects of quality care – Prevention– Chronic Care Management– Acute Episode of Care Management– Procedural Related Care– Resource Utilization– Care Coordination

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Understanding the Measures:Construct

Clinical action required for reporting and performance

________________________________Eligible cases for a measure (the eligible

patient population associated with the numerator)

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Understanding the Measures:Construct

CPT II Codeor

Temporary G Code ________________________________

ICD-9-CM and

CPT Category I Codes

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Understanding the Measures:Quality Data Codes

Quality-Data Codes translate clinical actions so they can be captured in the administrative claims process

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Understanding the Measures:Quality Data Codes

• Quality-Data Codes can relay that:– The measure requirement was met

or– The measure requirement was not met due to

documented allowable performance exclusions (i.e., using performance exclusion modifiers)

or– The measure requirement was not met and the

reason is not documented in the medical record (i.e., using the 8P reporting modifier)

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Understanding the Measures: The Performance Modifiers

• Performance Measure Exclusion Modifiers indicate that an action specified in the measure was not provided due to medical, patient or systems reason(s) documented in the medical record:

– 1P- Performance Measure Exclusion Modifier due to Medical Reasons– 2P- Performance Measure Exclusion Modifier used due to Patient

Reason– 3P- Performance Measure Exclusion Modifier used due to System

Reason• One or more exclusions may be applicable for a given

measure. Certain measures have no applicable exclusion modifiers. Refer to the measure specifications to determine the appropriate exclusion modifiers.

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Understanding the Measures: The Reporting Modifier

• Performance Measure Reporting Modifier facilitates reporting a case when the patient is eligible but the action described in a measure is not performed and the reason is not specified or documented– 8P- Performance Measure Reporting

Modifier- action not performed, reason not otherwise specified

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Understanding the Measures: Performance Time Frame

• Some measures have a Performance Timeframe related to the clinical action that may be distinct form the reporting frequency. – Perform within 12 months– Most Recent

• Clinical test result needs to be obtained, reviewed, reported one time. It need not have been performed during the reporting period.

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Understanding the Measures: Reporting Frequency

• Each measure has a Reporting Frequencyrequirement for each eligible patient seen during the reporting period – Report one-time only– Report once for each procedure performed– Report for each acute episode

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Coding for Quality:PQRI Coding

ExamplesOf

Measures

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Coding for Quality:Example - Procedure Related Care

Measure # 20 – Timing of Antibiotic Prophylaxis –

Ordering Physician

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39Current Procedural Terminology ©Association. All Rights Reserved.

2006 American Medical

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40Current Procedural Terminology © 2006 American Medical Association. All Rights Reserved.

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Current Procedural Terminology © 2006 American Medical Association. All Rights Reserved.

Coding for Quality:PQRI 2008

Additional Considerations

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PQRI 2008:Registries and EHR-based Data Submission

• CMS plans to test two options for registry-based data submission

• Self-nomination letters must be received by 6pm EST on January 4, 2008

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PQRI 2008:Registries and EHR-based Data Submission

• CMS plan to test the feasibility of offering eligible professionals the option of submitting clinical quality data extracted from EHRs directly to a data warehouse.

• Self-nomination letters are due by 6pm EST on January 4, 2008

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Coding for Quality:PQRI Readiness

Ensuring Success

Current Procedural Terminology © 2006 American Medical Association. All Rights Reserved. 46

PQRI Reporting: Ensuring Success

• Start reporting early to increase the probability of achieving the 80 percent rate of reporting during the reporting period.

• Report on as many measures as possible to increase the likelihood of achieving successful reporting.

• Report on as many eligible patients as you can to decrease the probability of being subject to the bonus cap.

• Ensure that quality codes are reported on the same claim as the diagnosis or CPT-I codes.

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PQRI Reporting:Ensuring Success

• Educational Resources– CMS PQRI website contains all publicly available

information at: www.cms.hhs.gov/PQRI• Frequently Asked Questions• PQRI Fact Sheet• Medicare Carrier/Medicare Administrative Contractor (MAC)

inquiry management