ED Coding and Reimbursement Alert

Back again for 2010 is Medicare's incentive-driven physician quality reporting initiative (PQRI), aimed at tracking quality metric or patient care services that physicians provide. When the practice treats enough patients in the same category, some PQRI dollars might be only a few codes away.

If you know the basics and focus your efforts, PQRI reporting can be a breeze and a boon to your bottom line. Check out this rundown on "The Whats?" of PQRI.

Coders can garner an extra payout for PQRI-eligible patients that your group treats and you code correctly; for 2010, Medicare will fork over a 2 percent bonus if you meet certain criteria.

Lowdown: In order to qualify for the PRQI bonus, you have to report on at least three of 179 PQRI measures in 80 percent of the eligible cases, explains Alice Marie Reybitz, RN, BA, CPC, CPC-H, CHI, a healthcare coding and billing consultant based in Belleair, Fla. (Check out the PQRI measures list at http://www.cms.hhs.gov/PQRI/Downloads/2010_PQRI_MeasuresList_111309.pdf.)

The devil's in the details with PQRI reporting. To properly report PQRI measures, you need to report a series of codes that corresponds to a PQRI numerator and denominator, explains Eileen Lane-Coffill, CPC, PCS, senior compliance auditor at Boston's HMFP Compliance.

Breakdown: "The numerator is the ICD-9 and CPT category I code, and the denominator is the CPT category II code[s]," Coffill says. This category II code is usually an F code -- or "PRQI code."

Get to know the PQRI codes, which you'll find on the PQRI Web site listed above. The PQRI codes represent the measure that you are reporting on; leave these off a claim, and you cannot count it toward PQRI.

Example: The ED physician provides a level-four ED E/M service to a patient complaining of chest pain; final diagnosis is precordial chest pain. This encounter qualifies for PQRI measure 54 (12-lead electrocardiogram [ECG] performed for non-traumatic chest pain).

Patients who qualify for measure 54 will be common in many EDs, confirms Caral Edelberg, CPC, CCS-P, CHC, president of Medical Management Resources for TeamHealth in Jacksonville, Fla. To qualify for PQRI, code this claim as follows:

• Numerator: 99284 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: a detailed history; a detailed examination; and medical decision making of moderate complexity ...) for the E/M with 786.51 (Precordial pain) appended to represent the patient's condition.

• Denominator: 3120F (12-lead ECG performed [E/M]) to represent the PQRI measure. Each measure has its own set of diagnosis requirements. Coders are allowed to report on measure 54 for patients with a diagnosis of precordial pain (786.51).

Some other acceptable diagnoses for measure 54 include:

413.0 (Angina decubitis), 413.1 (Prinzmetal angina),

413.9 (Other and unspecified angina pectoris), 786.50 (Chest pain, unspecified).

Use this: Coding for PQRI without using the PQRI Tool Kit is as futile as flying a kite with no string. The link for the kit is http://www.cms.hhs.gov/PQRI/31_PQRIToolKit.asp#TopOfPage. Bookmark this site and visit it often. From this page, information regarding how to code each measure properly flows.

Each measure has a reporting frequency requirement for services furnished during the reporting period -- report a PQRI measure for each patient to whom the measure applies one time only for each service (performed once per acute episode), explains Edelberg.

Example: Consider the Medicare explanation under measure 28: "This measure is to be reported each time during the reporting period a patient has been discharged from the emergency department with a diagnosis of AMI.

Patients who are discharged from the emergency department with a diagnosis of AMI should have documentation in the medical record of having received aspirin 24 hours before emergency department arrival or during emergency department stay."

For 2010, CMS has continued to increase the available mechanisms for submitting PQRI codes, explains Sarah Todt, RN, CPC, CEDC, associate director for QA and compliance at MRSI Inc. in Woburn, Mass. Most ED groups submit through a claims-based process, meaning the PQRI codes are reported directly on the claim. CMS continues to emphasize expansion of options beyond simply claims submission to include reporting PQRI via a qualified electronic health record (EHR) product or a registry.

"Previously, PQRI may have been reported for individual physicians via Part B claim or a qualified PQRI registry," says Todt.

You should come up with a list of three or more measures that the practice will focus on for PQRI. "It's important to understand the reporting period for each measure you select to report. Be sure all ED clinicians have been in-serviced to the measures you have identified to assure documentation is complete," recommends Edelberg.

After that, just start looking for encounters that might fit your measures list. There is no sign-up process for PQRI: simply start reporting the proper numerators and denominators to Medicare for PQRI patients who fall into one of your selected measures, and the Feds will register it.

Of note: Medicare deleted measure 34 (Consideration of TPA for stroke) and replaced it with measure 187 (Stroke and stroke rehabilitation: thrombolytic therapy); though this measure requires reporting through a registry.

Good idea: Put an audit team in place to provide "error identification feedback to all involved in the [PQRI] process and validate your performance," according to Edelberg.