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Centers for Medicare & Medicaid Services

Physician Quality Reporting Initiative (PQRI)

Coding for Quality

Sylvia W. Publ, MBA, RHIASpecial Program Office,

Medicare Value Based Purchasing

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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 Readiness: Ensuring Success• PQRI 2008

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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:The Process

Visit Documented in the Medical Record

Encounter Form Coding & Billing

Carrier/MAC

NCH

Analysis Contractor National Claims History File

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: Key Information

• Reporting period: Dates of Service between January 1, 2008 through December 31, 2008

• No need to register: just begin reporting• Must be an enrolled Medicare provider (but need

not have signed a Medicare participation agreement)

• Need to use individual National Provider Identifier (NPI).

• Can still participate to practice quality reporting

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Coding for Quality:PQRI Tools

Implementing

PQRI

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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 Tool Kit:The Measure Finder

• Allows for search by multiple parameters– ICD9 Codes– CPT I Codes– CPT II Codes– HCPCS G- Codes

• Links to Data Work Sheets

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PQRI Tools: Coding for QualityA Handbook for PQRI Participation

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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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PQRI Tools:The Code Master

• Excel Spreadsheet– a sequential list of all ICD-9-CM (I9) – CPT ® (CPT4) codes (including CPT II Codes)– CPT II exclusion modifiers that are included in

the 2007 PQRI.

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Coding for Quality:PQRI Principles

Understanding the Measures

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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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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 Frequency requirement 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

Examples

Of

Measures

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Coding for Quality:Pathology Measures

• Breast Cancer patients who have a pT and pN category and histologic grade for their cancer

• Colorectal cancer patients who have a pT and pN category and histologic grade for their cancer.

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Coding for Quality:Example #1- Prevention

Measure #4 – Screening for Future Fall Risk

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35Current Procedural Terminology © 2006 American Medical Association. All Rights Reserved.

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36Current Procedural Terminology © 2006 American Medical Association. All Rights Reserved.

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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

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Questions?