ED Coding and Reimbursement Alert

Successful practices offer these tips to preparing for PQRI

ED coders are gearing up to participate in the Physician Quality Reporting Initiative (PQRI). They-re also finding ways to adapt to the PQRI's requirements, and you can learn from their examples.

Your physician may already be doing the things that PQRI asks about, but not documenting them. For a hospital-based practice, obtaining documentation directly from the hospital is important, says Donna Allshire, CPC, CPC-H, RCC, operations director with Professional Emergency Physicians in Fort Wayne, Ind.

Reference sheet: In a continuing effort -to educate and work with the physicians on [PQRI] documentation,- Allshire's staff created a special reference sheet, listing diagnosis codes along with the PQRI measures that go with them. 

-The coders review the hospital medical record for documentation so the appropriate PQRI measure is reported,- Allshire says.

Problem: -Currently there is no documentation to indicate why the patient didn't receive an EKG for syncope or aspirin for AMI,- Allshire says. -We don't know if it was the patient's decision or a medical contraindication.-

Find it online: When setting up your reference sheets, check out 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-).

Make Room for Quality Measure Recording

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, president and CEO of TERM Billing in Mansfield, Texas. Coders working with emergency physicians could miss the fact that a heart-attack patient received aspirin because it's in the ambulance run-sheets, the nurse's notes, the doctor's notes, or elsewhere.

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

(For more information on starting up your PQRI program, see the Reader Question -Use Tool Kit for Optimal PQRI Reporting- on page 74.)

Check PQRI Software Options to Ease Your Compliance Headaches

Meeting PQRI requirements might be easier if your software is set up to help, coders say. Some electronic documentation systems for emergency physicians provide your physician with an -addendum- to capture the quality measures, says Kristie Risley with Optimal Billing Solutions Jacksonville, Fla.

Tip: Work with your software vendor to make sure your system can accept the PQRI codes as valid and with a zero charge, Risley says. These codes have no payment amount, but if your system won't accept zero charge items, you could try listing them as having a reimbursement of $0.01 so your software can accept them.

Modifiers: You-ll have to learn to use four new modifiers to explain why your doctor didn't perform a particular quality measure: 1P (medical reasons), 2P (the patient declined it), 3P (system reasons), or 8P (not specified). These modifiers -are the most difficult piece to understand,- Risley says.

Solution: If you can't figure out why the doctor didn't perform a particular quality measure, you can always add modifier 8P, says Sandra Pinckney, CPC, coder at Certified Emergency Medicine Specialists in Grand Rapids, Mich.

But in that case, Pinckney will send the chart back to the physician asking for more information to limit the use of modifier 8P.