November 30, 2009
PQRI: Play Now or Pay Later
By Melissa Brown, RHIA, CPC, CPC-I, CFPC
Vol. 10 No. 19 P. 6
Eligible radiology practices can pocket an additional 2% of their total allowed Medicare charges for 2009 if they participate in the program enacted by Congress requiring the Centers for Medicare & Medicaid Services (CMS) to establish a physician quality reporting system known as the Physician Quality Reporting Initiative (PQRI). The PQRI includes an incentive payment for eligible professionals who satisfactorily report data on quality measures for covered services furnished to Medicare beneficiaries during a specified reporting period.
Congress made the PQRI a permanent program in 2008 following its trial run, but the language made no guarantees of incentives beyond 2010, something facilities should consider before participating. Eligibility for the bonus is calculated at the provider level, with bonuses generally being paid to the hospitals or practice plans (tax ID level).
The PQRI is the centerpiece of a push to help practices adjust to participation in the “pay-for-reporting” program with the goal being a transition to a pay-for-performance structure. Early models have penalties in the -2% range for all providers, with a 5% to 10% bonus provided to the highest performers. In these challenging economic times, it is even more important to learn the system of reporting (play now) so that you are not penalized (pay later) for not understanding the rules.
How to Participate
If you want to start voluntary participation while the system is still based on a reporting method, you will be relieved to know that you don’t have to fill out any enrollment forms. Participation begins when you submit the appropriate reporting codes.
Step 1: Review and select your measures. The CMS has published all the program’s details online at www.cms.hhs.gov/pqri. Review the list of quality measures and determine which ones apply most frequently to your Medicare fee-for-service patients. For example, diagnostic radiologists should consider Measure 10 — Stroke and Stroke Rehabilitation: Computed Tomography (CT) or Magnetic Resonance Imaging (MRI) Reports, or reports that include documentation of the presence or absence of hemorrhage and mass lesion and acute infarction; or Measure 11 — Stroke and Stroke Rehabilitation: Carotid Imaging Reports, or those that include direct or indirect reference to measurements of distal internal carotid diameter for stenosis measurement. There are several quality measures that would apply to radiology services, so you’ll want to review the list in detail. The ACR has published guidance on their interpretation of appropriate measures by specialty.
Step 2: Establish a data capture process. Physicians and billing staff collaboration is critical to success. Reporting is based on CPT category II codes, which are attached to standard CMS claim forms. Without physician buy-in, the documentation may lack necessary items; without staff training, claims may be filed without the quality data code(s) necessary for reporting.
The quality measures contain quality data codes in the form of CPT category II codes, which are used to report your performance or nonperformance of the measure. Note the key is to report—you will not be expected to perform the measure at this time but rather report whether or not you did. You will need to identify which patients the PQRI measures will apply to and then translate the clinical information into the administrative claims process.
In the example of Measure 10, CT or MRI claims with transient ischemic attack or stroke diagnoses also will need to contain the quality data code that represents the measures as follows:
• CPT II 3110F, Presence or absence of hemorrhage and mass lesion and acute infarction documented in final CT or MRI report, and CPT II 3111F, CT or MRI of the brain performed within 24 hours of arrival to the hospital; or
• CPT II 3112F, CT or MRI of the brain performed more than 24 hours after arrival to the hospital (Use this if the patient is not eligible for this measure because CT or MRI of the brain was performed greater than 24 hours after arrival to the hospital.); or
• CPT II 3110F with 8P, Presence or absence of hemorrhage and mass lesion and acute infarction was not documented in final CT or MRI report, reason not otherwise specified (Note the use of a reporting modifier [8P] to CPT category II code to report circumstances when the action described by the measure is not performed and the reason is not otherwise specified.), and CPT II 3111F, CT or MRI of the brain performed within 24 hours of arrival to the hospital.
Step 3: Monitor your progress. Successful reporting of a quality measure requires a minimum of 80% of all applicable claims to contain the appropriate quality data codes. What makes this a bit tricky is that the quality data code must be reported on the initial claim with the payable service that was rendered. There are no second chances to refile the claim with the missing quality data code if it is omitted the first time.
If more than three measure sets apply to your patient mix, you will need to report successfully on a minimum of three quality measures. If fewer than three apply, you will need to report successfully on all applicable measures. (If you report on fewer than three measures, you may be subject to the Measure-Applicability Validation process.)
At the end of the reporting period, the CMS will provide feedback reports that summarize your reporting history. If you wait for the official CMS report, you will lose all chance of fixing reporting glitches in time to salvage any possible incentive payments. Tracking your own progress on a monthly basis allows you to identify claims that are missing the quality data codes and investigate the root of the issue. It may be that the provider is performing the measure but the administrative claims process is missing the information or another provider may not be aware of the necessary documentation. By monitoring progress, you can identify the issues in time to make adjustments and capitalize on the incentive.
— Melissa Brown, RHIA, CPC, CPC-I, CFPC, is the manager of education and reimbursement at the University of Florida Jacksonville Physicians, Inc. Her areas of expertise include financial analysis, the Physician Quality Reporting Initiative, and assorted coding-related topics.