Cardiology Coding Alert

Is Medicare the secondary payer? Watch for this common mistake.

Pay-for-performance is not going away, and PQRI is an opportunity to establish a data capture plan now so your future transitions will be even easier. Thats the word from a March 18 American College of Cardiology/CMS open door forum offering advice on improving PQRI success. Here are the highlights for claims-based reporting.

Dont Waste Time on Measure 7

Coding professionals who are scratching their heads looking for measure 7 (Beta-blocker therapy for CAD patients with prior MI) -- which was available in 2008 -- should look no further.

Youll notice that measure 7 is gone, said John Schaeffer, MD, president of the North Ohio Heart Center in Avon, Ohio, on the call. Measure 7 has been removed because it turned out to be very, very difficult, Schaeffer said. It had one of the highest failure rates. In the range of 85 percent of the time, we were not reporting that correctly, probably because it required two ICD-9 codes. So CMS decided to remove this from the claims base.

Keep These Measures Close at Hand

However, Schaeffer said, you can still use the following cardiology measures:

" Measure 5 --ACE or ARB therapy prescribed for heart failure patients with LVSD

" Measure 6 --Anti-platelet therapy prescribed for CAD patients

" Measure 8 --Beta-blocker therapy prescribed for heart failure patients with LVSD

" Measure 118 --ACE or ARB therapy prescribed for CAD patients with diabetes or LVSD

" Measure 152 -- Lipid panel for CAD patients.

Tip: You must report the quality data codes (QDC) on the same claim as the ICD-9 and E/M codes (which supply the measure denominator) to qualify for claims-based submission, Schaeffer said. The QDC may be either a CPT Category II or HCPCS code.

For example: Suppose youre reporting measure 6.Eligible ICD-9 codes are 410.xx-414.07, 414.8, 414.9,V45.81, and V45.82. Eligible E/M codes are 99201-99205, 99212-99215, 99238-99245, 99304-99310, 99324-99337, and 99341-99350. So you would choose the appropriate diagnosis code and E/M code based on the documentation and report them on the claim.

On the same claim, you report the QDC numerator code, which for this measure is 4011F (Oral antiplatelet therapy prescribed [e.g., aspirin, clopidogrel/Plavix, or combination of aspirin and dipyridamole/Aggrenox] [CAD]). So you would report 4011F if the cardiologist prescribed aspirin, copidogrel, etc. (For a listing of measures and codes, see the 2009 PQRI Measure Specifications Manual at www.cms.hhs.gov/PQRI/ on the Measures/Codes page.)

Modifier must: If the cardiologist didnt prescribe antiplatelet therapy for an eligible patient, he needs to document an exception, Schaeffer said. And you need to add the appropriate modifier to 4011F, he explains: " 1P (& due to medical reasons) indicates the physician chose not to prescribe, such as when a patient has an active peptic ulcer disease and is bleeding, and its not safe for anti-platelet therapy

" 2P (& due to patient reasons) means the patient chose not to take the therapy, which is often cost-related

" 3P (& due to system reasons) applies, for example, when there is not insurance coverage for the medication prescribed.

CMS also offers modifier 8P (... action not performed,reason not otherwise specified) for use when the cardiologist doesnt specify the reason he didnt perform the action described in the QDC.

These modifiers are the only ones you should use with the Category II QDCs, said Sylvia Publ, MBA, RHIA,senior quality advisor in CMS office of clinical standards of quality, during the call.

Case in point: One caller indicated her practice had been appending modifier Q6 (Service furnished by a locum tenens physician) to QDCs for services by a locum tenens. Publ responded Q6 is not a modifier to be used with quality data codes. [1P, 2P, 3P, and 8P] are the only ones that we allow for a quality data code.

Follow These Success Story Examples

In prior years, the practices that took careful, strategic approaches to PQRI were more successful than those that just reported a code on the claim and forgot about it, said Publ.

Increase success odds: To ensure that your PQRI has a better shot at succeeding, you should establish a PQRI team that includes physicians, nurses, coders, billers, and administrators, Schaeffer said. In addition, you should analyze the specifics of the PQRI program, and ensure that youre billing accurate diagnoses.

Physician involvement is mandatory, payback is obvious, theres an economic return, and of course, the most important thing is we get better patient care and better documentation, Schaeffer said.

What works: Prairie Cardiovascular Consultants CFO Ed Brooks shared some of the secrets to this Illinois practices 100 percent satisfaction and reporting rate in 2007:

1. Carve out space on the charge ticket for the physician to fill in PQRI information.

2. Require the physician to fill in PQRI information for every patient -- Medicare or not -- at the time of service. That way the physician doesnt have to decidewhether the patient is PQRI-eligible, and the coder always has the information she needs.

3. Beware of patients with Medicare as secondary coverage. Your electronic system may drop the PQRI code, so you may have to develop a process to manually enter PQRI codes for the Medicare claim.

Resource: For additional tips and to review the complete presentation materials for the March 18 ACC call, including documentation guide templates, visit www.acc.org/advocacy/advoc_issues/medicare_pqri031209.cfm.

Other helpful resources are available at www.acc.org/advocacy/advoc_issues/claimsbasedCMS.htm and www.cms.hhs.gov/PQRI/.