Cardiology Coding Alert

If your cardiology practice wants to participate in the Physician Quality Reporting Initiative (PQRI), you'll need to know which category II codes to report -- and when.

See how other practices are preparing, and what you should do to make certain you receive that extra Medicare reimbursement.

What it is: PQRI is a voluntary program that will provide a financial incentive to physicians and other eligible professionals who successfully report quality data related to services provided under the Medicare Physician Fee Schedule between July 1 and Dec. 31, 2007, according to CMS.

Common misconception: You don't have to register for the PQRI, experts say. Instead, you just have to start reporting special category II codes on your claims. The category II codes should be on the same claim as the visit they apply to.

For example: Your practice sees a lot of patients with coronary artery disease (CAD) who have had a prior myocardial infarction (MI) and therefore decides to report on measure seven.

Then, every time a patient comes in with CAD and a prior MI, you will examine the documentation to see whether your physician prescribed beta-blocker therapy.

If the physician did, you will add CPT code 4006F (Beta-blocker therapy, prescribed [CAD, HF]) to the claim.

If the physician didn't, you'll have to learn to use four new modifiers to explain why. These modifiers "are the most difficult piece to understand," says Kristie Risley with Sterling Healthcare in Durham, N.C.

If the physician did not prescribe beta-blocker therapy for medical, patient or system reasons, you'll add one of these modifiers to 4006F:

• 1P -- Documentation of medical reason(s) for not prescribing beta-blocker therapy

• 2P -- Documentation of patient reason(s) for not prescribing beta-blocker therapy

• 3P -- Documentation of system reason(s) for not prescribing beta-blocker therapy.

If the physician didn't prescribe beta-blocker therapy for an unknown reason, you'll add modifier 8P (Beta-blocker therapy was not prescribed, reason not otherwise specified) to 4006F. But in that case, send the chart back to the physician asking for more information to limit the use of modifier 8P, says Sandra Pinckney, CPC, coder at Certified Emergency Medicine Specialists in Grand Rapids, Mich. Using 8P means the physician is not taking credit for that service.

Result: If your quality reporting meets standards, you get an extra 1.5 percent of all of your Medicare billings from July 1 to Dec. 31. To receive the bonus, your doctor must report on up to three measures per claim.

Recipe for success: Remember that how many measures may apply to your patients doesn't matter, says Robert La Fleur, MD, an emergency medicine physician and president of Medical Management Specialists in Grand Rapids, Mich.

What's important: You just have to report on three measures per claim at least 80 percent of the time when that measure applies to any patient seen by the physician. And, for now at least, the PQRI has nothing to do with performance. You get paid regardless of whether your doctor actually performed the measures you're reporting on.

Keep in mind: There's a cap that might reduce your bonus amount if your doctor meets the 80 percent requirement but doesn't report measures very often. The cap is designed to reduce the bonus for providers who meet the requirements but still don't report on quality measures often enough. That way, if you report on quality measures only a few times, you won't get the full 1.5 percent bonus.

Your practice has two ways to choose which PQRI measure to report on.

Strategy 1: Pick manageable measures. Coders like Barbara McAneny, MD, a physician with a consultant practice in Albuquerque, suggest picking a measure on a set of patients that are easy to identify but may not be the most common condition you see in the practice.

Strategy 2: Pick common measures. "We chose three measures that we see almost every day," says Vanessa Luther, a coder with Racine Emergency Physicians. She's already prepared to add the category II codes when she submits the claims, and her physicians' documentation already includes the quality information she needs.

Bright side: "I actually think this will be kind of fun as it gives me something else to look at," Luther says. "I am sure I will miss a couple here and there, but my goal is 100 percent."

Practices are gearing up to participate in PQRI, and they're finding ways to adapt to the PQRI's requirements -- you can learn from their examples.

Encounter forms: "We are adding the codes to our encounter forms, including the modifiers, with instructions to use them if a patient is to be excluded," says Bob Lloyd, CEO of Mid-State Cardiology in Nashville, Tenn.

Note: Your physician may already be doing the things that PQRI asks about but not documenting them. Inform your physicians of what they need to document in their report by looking at the PQRI measures your practice has decided to take on, so that all you need to do is extract the information.

For a hospital-based practice, "it's important to obtain documentation directly from the hospital," says Donna Allshire, operations director with Professional Emergency Physicians in Fort Wayne, Ind.

Reference sheets: Allshire's staff created a special reference sheet, listing diagnosis codes along with the measures that go with them. At first, the coders will turn every Medicare chart sideways or pull it out of the stack. Then the coders can look through specifically for places to add the PQRI measures.

"I'm sure for the first month this will slow our coding staff down and their productivity will drop," Allshire says. "But we are hoping this will improve as everyone gets used to the new measures."

Also, you can create an attachment to your practice's fee slips with measures listed on them. This will remind the physicians to document any measures and then mark them on the attachment. Use information from the latest version of Coding for Quality: A Handbook for PQRI Participation, which you can download from www.cms.hhs.gov/pqri (click on "educational resources").

Watch out: You need a separate space for the physician to note whether he performed these quality measures -- even if the information is already in the chart somewhere, says Jackie Davis-Willett, CHMBE, president and CEO of TERM Billing in Mansfield, Texas.

Note: Medicare finally published a "PQRI Code Master," which is an Excel spreadsheet of ICD-9 and CPT codes, along with the measures that apply to them (also available at www.cms.hhs.gov/pqri). This could be helpful in picking which measures to report, says Eric Sandhusen, MPH, CHC, CPC, director of reimbursement, HIPAA and fiscal compliance with Columbia University department of surgery.

Check your software: Some programs, such as T-System Inc.'s T SystemEV program for emergency physicians, provide your physician with an "addendum" to capture the quality measures, Risley says.

"We're doing the PQRI quality reporting through our electronic medical records. The system looks for certain diagnoses and criteria and checks it against the med lists and contraindications," says Jennifer Crowell, CPC-EMS, hospital coordinator at Spokane Cardiology in Wash.

In other words, the system will first determine whether the patient has Medicare and, if yes, then compare the CPT codes and ICD-9 codes against those included in Measures 5 through 8, which are:

• Measure 5: Heart failure: angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) therapy for left ventricular systolic dysfunction (LVSD).

• Measure 6: Oral antiplatelet therapy prescribed for patients with coronary artery disease

• Measure 7: Beta-blocker therapy for coronary artery disease patients with prior myocardial infarction (MI)

• Measure 8: Heart failure: beta-blocker therapy for left ventricular systolic dysfunction.

How it works: If the CPT and ICD-9 codes match, the system then looks to the medications table to determine if the patient is on therapy. If yes, it automatically applies the appropriate code(s). If the patient is not on therapy, the system looks to see if the patient has a contraindication, and if yes, the system again automatically applies the category II codes. If it cannot find a contraindication to the code, it then places the visit on hold to be reviewed by a nurse. For Measures 5 and 8, the system also finds the last ejection fraction and codes appropriately, Crowell says.

Tip: Work with your software vendor to make sure your system can accept the PQRI codes as valid, Risley says. Because these codes have no payment amount, you could try listing them as having a reimbursement of $0.01 so your software can accept them.