Centers for Medicare Medicaid Services Physician Quality Reporting

Centers for Medicare & Medicaid Services Physician Quality Reporting Initiative (PQRI) Coding for Quality Sylvia W. Publ, MBA, RHIA Special Program Office, Medicare Value Based Purchasing 1

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 2

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. 3

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 4

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 5

PRQI Introduction: The Process Visit Documented in the Medical Record Encounter Form Coding & Billing NCH Analysis Contractor Confidential Report National Claims History File Carrier/MAC Bonus Payment Procurement Sensitive 6 6

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 Procurement Sensitive 7 7

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 8

Coding for Quality: PQRI Tools Implementing PQRI 9

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. 10

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 11

PQRI Tools: MLN 5640: Coding and Reporting Principles Procurement Sensitive 12 12

PQRI Tools: The Measure List Procurement Sensitive 13 13

PQRI Tool Kit: The Measure Finder • Allows for search by multiple parameters – – ICD 9 Codes CPT II Codes HCPCS G- Codes • Links to Data Work Sheets Procurement Sensitive 14 14

PQRI Tools: Coding for Quality A Handbook for PQRI Participation Procurement Sensitive 15 15

PQRI Tools: Coding for Quality A 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 16

PQRI Tools: Coding for Quality A Handbook for PQRI Participation Examples of Clinical Conditions/Topics • 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 17

PQRI Tools: Measure- specific Data Collection Worksheets • Measure Specific – Measure Description – Worksheet – Coding Specifications 18

PQRI Tools: The Code Master • Excel Spreadsheet – a sequential list of all ICD-9 -CM (I 9) – CPT ® (CPT 4) codes (including CPT II Codes) – CPT II exclusion modifiers that are included in the 2007 PQRI. 19

Coding for Quality: PQRI Principles Understanding the Measures 20

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 21

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 22

Understanding the Measures: Construct Clinical action required for reporting and performance ________________ Eligible cases for a measure (the eligible patient population associated with the numerator) 23

Understanding the Measures: Construct CPT II Code or Temporary G Code ________________ ICD-9 -CM and CPT Category I Codes 24

Understanding the Measures: Quality Data Codes Quality-Data Codes translate clinical actions so they can be captured in the administrative claims process 25

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 8 P reporting modifier) 26

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: – 1 P- Performance Measure Exclusion Modifier due to Medical Reasons – 2 P- Performance Measure Exclusion Modifier used due to Patient Reason – 3 P- 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. 27

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 – 8 P- Performance Measure Reporting Modifier- action not performed, reason not otherwise specified 28

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. 29

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 30

Coding for Quality: PQRI Coding Examples Of Measures 31

Coding for Quality: Pathology Measures • Breast Cancer patients who have a p. T and p. N category and histologic grade for their cancer • Colorectal cancer patients who have a p. T and p. N category and histologic grade for their cancer. 32

Coding for Quality: Example #1 - Prevention Measure #4 – Screening for Future Fall Risk 33

Procurement Sensitive 34 34

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

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

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 37

Questions? 38