1 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

2 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

3 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.

4 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

5 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

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

Procurement Sensitive 7 7 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

8 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

9 Coding for Quality: PQRI Tools Implementing PQRI

10 PQRI Tools: Where to Begin Gather information and educational materials from the PQRI web page: on the CMS website. Gather information from other sources, such as your professional association, specialty society or the American Medical Association.

11 PQRI Tools: The PQRI Website –Overview –CMS Sponsored Calls –Statute/Regulations/Program Instructions –Eligible Professionals –Measures/Codes –Reporting –Analysis and Payment –Educational Resources

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

Procurement Sensitive 13 PQRI Tools: The Measure List

Procurement Sensitive 14 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

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

16 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

17 PQRI Tools: Coding for Quality A 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

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

19 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.

20 Coding for Quality: PQRI Principles Understanding the Measures

21 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

22 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

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

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

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

26 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)

27 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.

28 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

29 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.

30 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

31 Coding for Quality: PQRI Coding Examples Of Measures

32 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.

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

Procurement Sensitive 34

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

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

37 PQRI Reporting: Ensuring Success Educational Resources –CMS PQRI website contains all publicly available information at: Frequently Asked Questions PQRI Fact Sheet Medicare Carrier/Medicare Administrative Contractor (MAC) inquiry management

38 Questions?