ED Coding and Reimbursement Alert

Medicare recently renewed the Physician Quality Reporting Initiative (PQRI) for 2008, giving EDs another opportunity to fatten their bottom lines by reporting on certain measures.

The basics: The new PQRI period began Jan. 1, 2008, and will run until Dec. 31, 2008, said Eli Berg, MD, FACEP, during his recent Coding Institute teleconference "Best ED Coding Practices: Get on the Right Foot for 2008."

This year, Medicare laid out 119 measures for physicians to report, says Michael A. Granovsky, MD, CPC, FACEP, president of Medical Reimbursement Systems Inc. (MRSI), an ED billing company in Woburn, Mass. If you successfully report from the set of quality measures that apply to EDs, you can receive reimbursement for up to 1.5 percent of all your Medicare billings -- the same rate you saw in 2007 -- during the reporting period.

Check out this primer on the ED-specific PQRI quality measures. It will show you what measures to report, how to report them, and how to make the whole process more palatable for coders and physicians.

To receive the Medicare bonus, your providers will have to report on at least 80 percent of cases for three measures on the PQRI list, said Berg, who is the CEO of MRSI. The bonus will apply to all allowable Medicare charges, including deductibles and copayments.

For now, PQRI scoring is tied only to reporting; however, this is the time to get your systems in order. Ultimately, CMS envisions tying payment to successful performance of these measures, Granovsky says.

The current list of measures contains seven primary ED-relevant entries, Berg said. (For a list of those entries, see "Coders Can Count on These PQRI Resources" on page 43.)

Best bet: Find the three measures your ED reports the most and focus on those. For example, if your ED treats a lot of heart attack patients, you might consider focusing on Measure 28 -- "Aspirin at Arrival for Acute Myocardial Infarction (AMI)." If the ED satisfies the PQRI requirements for at least 80 percent of its patients on three measures, it is eligible for the Medicare bonus.

For accurate PQRI reporting, you-ll need to code the proper diagnosis and CPT code for the service, then you-ll have to choose a category II code for tracking purposes. If your coding does not line up with PQRI's expectations, don't expect the bonus.

Example: You are reporting on Measure 28. According to Medicare's "2008 Physician Quality Reporting Initiative Specifications Document," you should report this measure "each time during the reporting period a patient has been discharged from the emergency department with a diagnosis of AMI (acute myocardial infarction). 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. It is anticipated that clinicians who provide care in the emergency department will submit this measure."

So to meet this measure, you-ll first need to report the appropriate ED visit code (99281-99285 or 99291) and the ICD-9 code for AMI, Granovsky says.

According to Medicare, the ED codes that trigger a reporting requirement are 99281-99285 and 99291. The diagnosis codes describing AMI include 410.01, 410.11, 410.21, 410.31, 410.41, 410.51, 410.61, 410.71, 410.81 and 410.91.

"The AMI reporting requirement is limited to cases where both 99281-99285 or 99291 and ICD-9 code 410.x are reported on the (same) claim," Berg says. "When Medicare sees this code combination, it expects to see a PQRI code."

Suppose the physician provides a level-five E/M for a patient who suffered AMI of the anterolateral wall (initial care episode). Notes indicate that the patient was given aspirin in the ED. You-d report 99285 (Emergency department visit for the evaluation and management of a patient, which requires these three key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: a comprehensive history; a comprehensive examination; and medical decision-making of high complexity) for the E/M along with the ICD-9 code 410.01 (Acute myocardial infarction; of anterolateral wall; initial episode of care) appended to prove medical necessity.

To qualify the above encounter for PQRI, you-ll next need to choose a category II code. According to Medicare, you should include 4084F (Aspirin received within 24 hours before emergency department arrival or during emergency department stay) on the claim to meet PQRI standards.

Note: The PQRI codes are listed in the "Category II Codes" section of CPT 2008 as well as on the CMS Web site at http://www.cms.hhs.gov/pqri.

To help physicians and coders comply with PQRI, the AMA posted several data collection sheets, which you can use at your practice to keep up with Medicare's requirements. Check out the Measure 28 sheet online at http://www.ama-assn.org/ama1/pub/upload/mm/370/wrksht_28_08.pdf.

What should you do if the physician does not perform the specified quality measure on a patient whose encounter qualifies for PQRI?

You should still report the visit as your would any other PQRI encounter -- just remember to include the appropriate modifier to explain why the physician did not perform the measure, Berg says.

You have to learn to use four new modifiers to explain the specific action involved with the PQRI measure:

- 1P -- Exclusion modifier due to medical reasons

- 2P -- Exclusion modifier due to patient reasons

- 3P -- Exclusion modifier due to system reasons

- 8P -- Reporting modifier -- action not performed, reason not otherwise specified.

Example: The physician provides a level-five E/M for a patient who had AMI of the anterolateral wall (initial care episode). Because the patient is allergic to aspirin, he did not receive any during the encounter.

This scenario fits PQRI Measure 28, even if the physician did not administer aspirin, Granovsky says. To qualify this encounter for PQRI, report the following:

- 99285 for the E/M

- 410.01 linked to 99285 to represent the AMI

- 4084F to represent the PQRI measure

- modifier 1P linked to 4084F to show that the physician did not meet the quality measure due to a medical reason.