A Physiatrist’s Guide to the Centers for Medicare and Medicaid Services’ Physician Quality Reporting Initiative

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


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


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


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


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


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


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


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


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


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


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


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


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


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


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.


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.


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


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


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


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


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


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

Documents

A Physiatrist’s Guide to the Centers for Medicare and Medicaid Services’ Physician Quality Reporting Initiative