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2009 PQRI for Urgent Care Providers. Introduction. The Problem Medicare Insolvency The Reality Drastic Measures The Hope Transform Medicare . Introduction. The First Step Physician Quality Reporting Initiative “Physician “Quality” “Reporting” “Initiative”. Introduction.

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introduction
Introduction
  • The Problem
    • Medicare Insolvency
  • The Reality
    • Drastic Measures
  • The Hope
    • Transform Medicare
introduction3
Introduction
  • The First Step
    • Physician Quality Reporting Initiative
      • “Physician
      • “Quality”
      • “Reporting”
      • “Initiative”
introduction4
Introduction
  • The Incentive
    • Successful Reporting
      • 80% threshold on 3 measures
    • Bonus Payment
      • 2% of total allowed charges for covered Medicare services during the reporting period
the plan of the presentation
The Plan of the Presentation
  • The principles of the program
  • The perks of participation
  • The projection for your practice
  • The props for preparation
  • The pick of the pertinent
  • The portion of the provider
  • The portion of the reporter
  • The process of reporting
  • The probe of poor performance
  • The prohibition of appeal
  • The perusal of personal performance
the principles of the program
The principles of the program
  • Voluntary program
  • Reporting based—not performance based
  • Claims-based reporting
  • Reporting period Jan 1 through Dec 31
  • Submission of clinical quality data
  • Potential bonus payment
  • Confidential feedback reports
the principles of the program7
The principles of the program
  • Focus of the measures
    • Prevention
    • Chronic-care management
    • Acute episodes of care management
    • Procedure related care
    • Resource utilization
    • Care coordination
  • Process of ensuring quality of care
the principles of the program9
The principles of the program
  • Eligible professionals
    • Physicians
    • Practitioners
    • Therapists
  • No registration necessary
  • Requires enrollment in Medicare
  • No participation agreement necessary
  • Must submit NPI (National Provider Identifier)
the principles of the program10
The principles of the program
  • 153 quality measures for 2009
  • Each measure has “Measure Specification” document
    • Measure Title
    • Measure Description
    • Instructions on Reporting (Frequency, Timeframes, and Applicability)
    • Numerator Coding
    • Definitions of Terms
    • Coding Instructions
    • Use of CPT Category II Exclusion Modifiers
    • Denominator Coding
    • Rationale Statement for Measure
    • Clinical Recommendations Forming the Basis for the Measure
the principles of the program11
The principles of the program
  • Calculation method
    • Percentage of a defined patient population that receive a particular process of care or achieve a particular outcome.
  • Denominator—indicates opportunity to report
    • Defined by ICD-9 and CPT Category I codes specified in the measure
    • Submitted as a initial line item on the claim to Medicare
  • Numerator—represents actual reporting
    • Defined by CPT Category II codes (or G codes—if no CAT II)
    • Submitted as a subsequent line item on the claim to Medicare
    • May be submitted with a Category II Exclusion Modifier
the principles of the program14
The principles of the program
  • CPT Category II codes
    • Supplemental tracking codes that debuted in 2003
    • Decrease the need for record abstraction and chart review
    • Minimizes administrative burdens on health care professionals
  • Exclusion modifiers
    • Indicates that an action contained in the measure was not provided for a specific reason
      • 1P: medical reasons
      • 2P: patient reasons
      • 3P: system reasons
  • Reporting modifier
    • Indicates that an action contained in the measure was not provided and the reason is not specified
      • 8P: action not performed, reason not otherwise specified
the principles of the program15
The principles of the program
  • Temporary G codes
    • Use when no category II code is available
    • Note that some G codes contain exclusion language within the description—so do not use any of the exclusion modifiers with a G code
    • Example (measure #8: beta-blocker therapy for heart failure)
      • G8450: beta-blocker therapy prescribed
      • G8451: beta-blocker therapy not prescribed for documented reasons
      • G8452: beta-blocker therapy not prescribed, reason not documented
the perks of participation
The perks of participation
  • Quality improvement
  • Patient satisfaction
  • Preparation for VBP
  • Potential bonus
    • Successful reporting (80% on 3 measures)
    • 2% of total allowed charges
    • Covered Medicare services
    • During the reporting period
    • One time lump sum payment (TIN)
the props for preparation
The props for preparation
  • CMS website
    • http://www.cms.hhs.gov/PQRI/
    • See “Measures/Codes”
    • See “PQRI Tool Kit”
  • AMA website
    • www.ama-assn.org/go/toolsMedicarePQRI
    • See “Participation Tools”
    • Step-by-step tool for clinical use and office/billing staff use.
the pick of the pertinent
The pick of the pertinent
  • Review list
    • 2009 PQRI Measures List
  • Select measures
    • 2009 PQRI Quality Measures Specifications Manual and Release Notes
      • See Denominator
      • See Instructions
    • http://www.cms.hhs.gov/PQRI/15_MeasuresCodes.asp#TopOfPage
  • Consider applicability
    • Common conditions
    • Usual treatment
    • Typical place of service
    • Improvement goals
the pick of the pertinent21
The pick of the pertinent

Possibly Urgent Care Quality Measures

  • Diabetes Mellitus
    • #3 Blood Pressure Measurement Documented
    • #126 Lower Extremity Neurological Exam
  • COPD
    • #51 Spirometry Results Documented
    • #52 Inhaled Bronchodilator Prescribed
  • Pneumonia
    • #56 Vital Signs Reviewed
    • #57 Oxygen Saturation Reviewed
    • #58 Mental Status Assessed
    • #59 Empiric Antibiotic Prescribed
  • No Condition Required
    • #110 Influenza Vaccination Query
    • #111 Pneumococcal vaccination Query
    • #114 Tobacco Use Assessed
    • #115 Smokers Advised to Quit
the pick of the pertinent22
The pick of the pertinent
  • Community-Acquired Bacterial Pneumonia
    • 56Vital Signs for Community-Acquired Bacterial Pneumonia
      • Percentage of patients aged 18 years and older with a diagnosis of community-acquired bacterial pneumonia with vital signs documented and reviewed
      • 99201-99205, 99212-99215
      • May include one of the following:
        • Clinician documentation that vital signs were reviewed
        • Dictation by the clinician including vital signs
        • Clinician’s initials in the chart that vital signs were reviewed
        • Other indication that vital signs were acknowledged by clinician
the pick of the pertinent23
The pick of the pertinent
  • Community-Acquired Bacterial Pneumonia
    • 57 Assessment of Oxygen Saturation for Community-Acquired Bacterial Pneumonia
      • Percentage of patients aged 18 years and older with a diagnosis of community-acquired bacterial pneumonia with oxygen saturation documented and reviewed
      • 99201-99205, 99212-99215
      • May include one of the following:
        • Clinician documentation that oxygen saturation was reviewed
        • Dictation by clinician including oxygen saturation
        • Clinician’s initials in the chart that oxygen saturation was reviewed
        • Other indication that oxygen saturation had been acknowledged by the clinician
the pick of the pertinent24
The pick of the pertinent
  • Community-Acquired Bacterial Pneumonia
    • 58 Assessment of Mental Status for Community-Acquired Bacterial Pneumonia
      • Percentage of patients aged 18 years and older with a diagnosis of community-acquired bacterial pneumonia with mental status assessed
      • 99201-99205, 99212-99215
      • Physician must document that patient’s mental status was noted (e.g., patient is oriented or disoriented)
the pick of the pertinent25
The pick of the pertinent
  • Community-Acquired Bacterial Pneumonia
    • 59 Empiric Antibiotic for Community-Acquired Bacterial Pneumonia
      • Percentage of patients aged 18 years and older with a diagnosis of community-acquired bacterial pneumonia with an appropriate empiric antibiotic prescribed
      • 99201-99205, 99212-99215
      • Drug Classes
        • Fluoroquinolones
        • Macrolides
        • Doxycycline
        • Beta Lactam with Macrolide or Doxycycline
the portion of the provider
The portion of the provider
  • For the eligible professional…
  • Review Measure Specification
  • In preparation—know the appropriate action
    • See Numerator
    • See Definition
    • See Rationale
    • See Clinical Recommendation Statement
  • With patient—identify the applicable condition; and
  • Consider whether to perform or not to perform the quality measure; and
  • Document performance or exclusion
    • See Definition for proper documentation of the measure
    • Document any reason why a measure could not be performed
the portion of the reporter
The portion of the reporter
  • For the medical coder…
  • Review Measure Specification
  • In preparation—know the applicable conditions
    • See Description
    • See Denominator
  • In preparation—know the applicable category II codes and exclusion modifiers or (if not available—the applicable G codes).
  • With the medical record—identify applicable conditions and determine if a quality measure should be reported.
  • Code performance or exclusion or failure to document
    • See Instructions
    • See Numerator
the process of reporting
The process of reporting
  • For the medical biller…
  • Category II codes (numerator) must be reported on the same claim as the payment codes (denominator)
  • Category II codes (or G codes) must be submitted with a line item charge of $0.00 or $0.01 (do not leave blank)
  • Some measures require the submission of more than one quality-data code in order to properly report the measure.
  • Eligible professionals may submit multiple codes for more than one measure on a single claim.
  • Multiple CPT Category II and/or G-codes for multiple measures that are applicable to a patient visit can be reported on the same claim, as long as the corresponding denominator codes are also line items on that claim.
  • Claims may not be resubmitted simply to add quality codes.
the process of reporting29
The process of reporting
  • For electronic claims…
  • Use the ASC X 12N Health Care Claim Transaction (Version 4010A1).
  • CPT Category II and/or temporary G-codes should be submitted in the SV101-2 “Product/Service ID” Data Element on the SV1 “Professional Service” Segment of the 2400 “Service Line” Loop.
  • It is also necessary to identify in this segment that a HCPCS code is being supplied by submitting the HC in data element SV101-1 within the SV1 “Professional Service” Segment.
  • Diagnosis codes are submitted at the claim level, Loop 2300, in data element HI01, and if there are multiple diagnosis codes, in HI02 through HI08 as needed. Pointers to appropriate diagnoses go in SV107-1 through -4
  • In general for group billing, report the NPI for the rendering provider in Loop 2310B (Rendering Provider Name, claim level) or 2420A (Rendering Provider Name, line level), using data elements NM108 and NM109.
the process of reporting30
The process of reporting
  • For paper claims…
  • Use the CMS 1500 claim form (version 08-05). Relevant ICD-9-CM diagnosis codes are entered in Field 21.
  • Service codes (including CPT, HCPCS, CPT Category II and/or G-codes) with any associated modifiers are entered in Field 24D with the diagnosis pointer in Field 24E.
  • For group billing, the National Provider Identifier (NPI) of the rendering provider is entered in Field 24J.
  • The Tax Identification Number (TIN) of the employer is entered in Field 25.
the process of reporting31
The process of reporting
  • If all of the services were provided by the same eligible professional then you do not need to include the NPI on each line item as long as the NPI is provided at the claim level.
  • Otherwise, if a group NPI is utilized at the claim level, then you must use the individual’s NPI number on each line item.
the probe of poor performance
The probe of poor performance
  • CMS is statutorily required to validate whether quality measures are appropriately reported when a reporting opportunity exists.
  • The validation will be performed on eligible professionals who successfully report on less than three quality measures.
  • A 2-step measure-applicability validation process will determine if they could have reported other measures applicable to the services that they usually provide.
    • First, a clinical relation test
    • Second, a minimum threshold test
the probe of poor performance33
The probe of poor performance
  • PQRI Measure Applicability Validation Process
    • http://www.cms.hhs.gov/PQRI/33_2007_General_Info.asp#TopOfPage
    • Certain general or broad measures applicable to all Medicare patients will be excluded
    • Clinical Relation Test
      • If a professional submits data for a measure, then the measure applies to his or her practice
      • If one measure related to a particular clinical focus area is applicable to a professional’s practice, then other closely-related measures in that same clinical area may also be applicable.
    • Minimum Threshold Test
      • If a professional treated more than a certain number of Medicare patients with a condition to which a certain measure applied, then that professional should be accountable for submitting the quality code for that measure
      • For 2007, the common minimum threshold will be 50 patient encounters for each measure.
the prohibition of appeal
The prohibition of appeal
  • CMS is statutorily restricted from allowing any administrative or judicial review of the determination of:
    • Quality measure applicability
    • Satisfactory reporting
    • Payment limitation or cap
    • Bonus incentive payment
  • But they will establish a process for professionals to ask questions about these issues.
the perusal of provider performance
The perusal of provider performance
  • CMS will provide confidential feedback reports in mid-2010.
  • The reports are expected to contain reporting and performance information at the individual NPI level and aggregated at the TIN level.
  • Purpose is to encourage quality improvement.
the perusal of provider performance36
The perusal of provider performance
  • For the Practice Manager
  • Go to https://applications.cms.hhs.gov
  • Go to account management and then new user registration
  • Follow the instructions.  You need to enroll as a security official and then fill in the information
  • Once you are enrolled and receive your username and password, login and go to your profile
  • Use the dropdown boxes to add a new application and choose PQRI user.
  • That will be approved once submitted and you’ll be able to use your login and password on the quality net website and view the reports
slide37

The End

Questions:

Kenneth Engel

CPC, CHC, ACS-EM, CCP-P

Vice President, Compliance Officer

Martin Gottlieb and Associates, LLC

kenny@gottlieb.com

1-800-833-9986