PQRI Participation Options

Simple Steps to Collect and Report Quality Data to Earn a

Medicare Bonus Payment

July 15, 2008

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Basic Concept

Select quality measures that are important to your practice and patients

Establish processes to systematically report the quality measures for each eligible patients

Reporting mainly done by including a quality code on claim

Receive feedback on extent to which patient got the recommended care described in the quality measure

Receive modest payment for effort

Use process to facilitate practice and patient care improvements

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PQRI Background; 2007 Program Federal law enacted in December 2006 established

PQRI

PQRI 2007 pays physicians 1.5% bonus for reporting quality measures July 1 – December 31, 2007

Select up to three measures applicable to practice from a list of 74 and report on 80% of eligible encounters for each measure selected; internists generally have to report three measures

Report against measures on standard CMS claim form

CMS determines who reported successfully and pays bonus and provides reporting/performance score feedback in mid-2008

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Sample PQRI Quality Measure Quality measure: LDL-C level in control (less than

100mg/dl)

Codes to report measure:

• CPT II 3048F: Most recent LDL-C < 100 mg/dL;

• CPT II 3049F: Most recent LDL-C 100-129 mg/dL; or

• CPT II 3050F: Most recent LDL-C ≥ 130 mg/dL.

• Can append modifier to indicate LDL not performed

Measure applies to beneficiaries with ICD-9 code indicating diabetes

Encounters on which to report measure are office, nursing facility, home, and domiciliary services

Reporting score is number of eligible patients/encounters divided by number of times reported measure

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Update on PQRI 2007 Status

Incentive payments for successful 2007 reporting issued mid-late July 2008

Payments issued to Tax ID Number (TIN) for all associated physicians who earned bonus

Feedback reports available mid-late July that provide reporting/performance score for each individual, for group, and national averages for comparison

• Individual physician or designated staff person needs to register with secure system to access confidential reports

CMS has mechanisms to help physicians with registration and receipt of reports

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PQRI 2008 Program Congress passed December 2007 law

continuing PQRI for 2008

Includes many features of the 2007 PQRI program

• Report codes for individual quality measures

• Report on up to three individual measures for at least 80% of eligible encounters

• Earn a 1.5% bonus

Additional changes/enhancements for 2008 PQRI

• Expansion from 74 to 119 measures

• Addition of two “structural measures”

• Additional reporting options

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Why Participate in PQRI 2008 Increase your ability to track patients with

common conditions, e.g. through practice management systems, use of patient registries

Promote team care and identify team member roles and responsibilities

Collect clinical information at the point of care, as opposed to retrospective chart review

Reporting quality codes on claims involves minimal burden when systems in place

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Why Participate in PQRI 2008

Learn about ability to routinely provide evidence-based care relevant to your patients

Receive modest payment

Gain experience in reporting and measuring against quality measures

• Programs likely to continue, and even grow, for Medicare and private payers

PQRI experience to inform and be a component of broader quality improvement strategy

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Quality Reporting and the PCMH ACP is a proponent of the Patient Centered

Medical Home delivery model

Quality reporting and measurement is a component of the PCMH

Medicare and private payers are developing tests of the PCMH

Practice transformation is to be supported by enhanced payment

Potential for broader availability of incentives that could enable internists to pursue PCMH recognition

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2008 Reporting Options Overview Alternate reporting periods and criteria

significantly increases participation/reporting options

• January 1 - December 31, 2008 (12 months)

• July 1 - December 31, 2008 (6 months)

Total of 9 PQRI reporting methods

• 3 claims-based

• 6 registry-based

Presentation focuses on claims-based options as most accessible to internists

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Claims-Based Options Reporting period: January 1, 2008 – December 31, 2008

• Option 1 – Report individual quality measures; internists report on three quality measures for 80% of eligible patients

Reporting period: July 1, 2008 – December 31, 2008

• Option 2 – Report a measure group for 15 consecutive eligible patients

• Option 3 – Report a measure group for 80% of eligible patients over the six month period

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Reporting Individual Quality Measures

If have reported on three individual quality measures through claims for the first half of 2008, continue to do so

• If reported in 2007, use CMS reporting/performance feedback from that year to assess whether to adjust 2008 participation

• CMS/AMA measure-specific “PQRI Data Collection Worksheets” are available at: http://www.ama-assn.org/ama/pub/category/17493.html

• ACP coding tool template with seven measures common to general internal medicine available at: http://www.acponline.org/running_practice/quality_improvement/performance_measurement/pqri/coding_tool.htm

Bonus payment for full-year successful reporting is 1.5% of Medicare allowed charges over the 12 month reporting period1

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Reporting Individual Quality Measures

It’s not to late to start reporting individual quality measures and hit the 80% threshold of eligible cases

Over 30 measures common to internal medicine practice need to be reported only once in the 12 month reporting period, including: diabetes; coronary heart disease; and some geriatrics measures

Requires a systematic way to identify those patients when they come in to the office

Could pick three diabetes measures, e.g. Hb A1c, LDL, blood pressure, or three screening measures, e.g. flu vaccine, pneumonia vaccine, and tobacco use inquiry

Assess whether patients eligible for selected measures have been seen in the office in the first six months of year/are likely to be seen in second half of the year

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Claims Options Available July 1; Measure Group Reporting

A measure group is a group of individual measures covering patients with a particular condition or preventive services

Report applicable measures in a measure group for 15 consecutive eligible beneficiaries; OR

Report applicable measures in a measure group for 80% of eligible beneficiaries during six-month reporting period

• Can earn bonus even if failed to report on 15 consecutive beneficiaries

Provides a potentially more straightforward reporting method

Bonus payment for successful reporting is 1.5% of Medicare allowed charges over the six month reporting period

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Measure Groups

Four measure groups, with number of individual measure number in parentheses, are:

• Diabetes Mellitus (5)

• End Stage Renal Disease (4)

• Chronic Kidney Disease (4)

• Preventive Care (9)

A single set of codes (CPT and/or ICD-9) as well as specific age ranges make up the denominator for each measures group

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Reporting Measure Groups

Need to submit the measures group specific G-code, e.g. G8485 for diabetes group, to signal intent to report group

• Submit measure group code on claim for first of 15 consecutive patients

• Submit measure group code even if you plan to use the 80% of eligible measures group cases option

The appropriate quality measure code must be submitted for each individual measure in the group that applies to each eligible patient

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Determining if a Patient Fits a Group

Step 1 – Does the measure group apply?

• Does the patient have the required denominator codes (CPT and/or ICD-9 codes) on the claim?

• Does the patient fit into the listed age range?

Step 2 – Does the individual measure apply?

• If the patient fits into the group but an individual measure does not apply due to age, gender, or diagnosis, you can choose not to report the measure OR report the measure with an exclusion modifier

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Diabetes Measure Group

DM group includes quality measures, with CMS-assigned number on list of 119 measures in parentheses

Hb A1c Poor Control (1)

LDL Control (2)

High Blood Pressure Control (3)

Dilated Eye Exam (117)

Urine Screening for Microalbumin (119)

All 5 measures apply to any patient who meets the denominator criteria—patient age 18-75 with a diagnosis of diabetes who comes in for an office visit

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Diabetes Measure Group

Patient Age

CPT Patient Encounter Codes

ICD-9 Codes

18-75 99201-99205; 99212-99215

250.00-250.03, 250.10-250.13, 250.2-250.23, 250.3-250.33, 250.4-250.43, 250.5-250.53, 250.6-250.63, 250.7-250.73, 250.8-250.83, 250.9-250.93, 648.0-648.04

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Reporting Diabetes Measure Group Report measure group specific G-code G8485 on first

patient to signal intent to report a measures group

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Reporting Diabetes Measure Group

Uniformity of denominator criteria—age, diagnosis, and office encounter—make diabetes measure group an attractive option

ACP developing coding tool for diabetes measure group

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Preventive Care Measure Group

Group includes quality measures, with CMS-assigned number on list of 119 measures in parentheses (numbers exceed 119 as CMS did not delete retired measure numbers) Screening/Therapy for Osteoporosis in Women 65+ (39)

Assessment of Urinary Incontinence in Women aged 65+ (48)

Influenza Vaccination for Patients > 50 years old (110)

Pneumonia Vaccination for Patients 65 Years and Older (111)

Screening Mammography (112)

Colorectal Cancer Screening (113)

Inquiry Regarding Tobacco Use (114)

Advising Smokers to Quit (115)

Weight Screening and Follow-up (128)

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Preventive Care Measure Group

Patient Age CPT Patient Encounter Codes

ICD-9 Codes

50 years and older

Applicable age varies by measure

99201-99205; 99212-99215

No specific diagnosis code required

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Reporting Preventive Care Measure Group

Report measure group specific G-code G8486 on first patient to signal intent to report measures group

No diagnosis code limitation may make it easier to report consecutive patients

Number of applicable measures in the nine measure group varies by patient gender and age, for example:

• Five measures apply to male patients 65-80 years old

• Nine measures apply to female patients 65-69

• Eight measures apply to female patients 70-80

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Reporting Preventive Care Measure Group

For individual measures in the measures group that do not apply to a particular patient due to age or gender requirements, you do not have to report the measure (you will not be penalized for reporting it with an exclusion modifier)

ACP developing coding tool for preventive care measure group

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Additional Measure Group Info

The complete specifications for the four measure groups can be viewed on the CMS PQRI website at www.cms.hhs.gov/pqri. Click on the Measures/Codes tab on the left side of the page.

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Registry-Based Options CMS will accept quality information reported

from a clinical registry on behalf of physicians

Registries collect physician-submitted data, typically related to a clinical condition or specialty

Registry data can be used a number of ways to earn a PQRI bonus payment

• Registry data for up to three individual measures for 80% of eligible encounters over the full year or last six months

• It can be used for a measure group for 30 or 15 consecutive patient or 80% of measure group eligible cases

Nature and duration of reporting determines if bonus payment is equal to allowed charges for 12 or 6 months

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Which Registries Can Report Quality Data CMS has asked existing registries to self nominate

CMS will announce registries it selects on its website by August 31

CMS tested receiving quality data from registries such as:

• National Cardiovascular Data Registry

• American Osteopathic Association

• Wisconsin Collaborative for Healthcare Quality

While CMS has yet to announce the registries that qualify, the testing provides an idea of the type of registries that will be able to report data

Relatively small number of internists likely have access to registry reporting option

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If You Submit Quality Data to a Registry

Contact the registry you use to see if it self-nominated to participate (deadline was May 31)

Inquire as to whether the registry believes it can meet the technical requirements to report to CMS

Express your interest in having your data submitted for purpose of PQRI

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Steps in Reporting Process

Select the measures/measure option you will use

Enlist team and assign roles and responsibilities

Put systems in place to facilitate reporting/quality improvement, e.g. registries, reminders, standing orders

Use a coding tool/worksheet

Attach a copy of the coding tool/worksheet to the super-bill to alert coder to enter appropriate quality codes

Coder verify patient eligibility, pertinent encounter, and correct quality codes

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Steps in Reporting Process

Include the NPI for each physician on claim

Keep a log of information for QI

Analyze your own data to improve as CMS unable to provide feedback until mid-2009

Use experience to establish/refine systems aimed at improvement

Look for other opportunities and bonus payments in your market

Cultivate a positive environment for quality improvement

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ACP PQRI Resources to Aid Participation

Coding Tools

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ACP PQRI Resources to Aid Participation

Evidence behind measures through PIER decision support

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Internist Reporting Experience

At least one ACP member will discuss PQRI participation experience

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Questions/Feedback

Conference call question & answer period

Send questions after the forum to pqri@acponline.org

Provide feedback on the PQRI and this conference call forum at http://www.acponline.org/running_practice/practice_management/payment_coding/pqri.htm

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