Gastroenterology Coding Alert

Experts warn that learning modifiers might be the trickiest part

If your gastroenterology practice wants to participate in the Physician Quality Reporting Initiative (PQRI), then you'll need to know what 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.

How It Works

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 December 31, 2007.

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 gastroesophageal reflux disease (GERD) and therefore decides to report on measures 60-63.

Then, every time a patient comes in with GERD, you will examine the documentation to see whether your
physician checked the patient for alarm symptoms (such as involuntary weight loss, dysphagia and GI bleeding). That's measure number 60.

If the physician did, you will add CPT code 1070F (Alarm symptoms [involuntary weight loss, dysphagia, or gastrointestinal bleeding] assessed; none present) or 1071F (... one or more present) to the claim.

If the physician didn't check the alarm symptoms, you will still report 1070F or 1071F, but you'll also attach a modifier (1P, Documentation of medical reason[s] for not documenting presence or absence of alarm symptoms) to the F code.

Result: If your quality reporting meets standards, you get an extra 1.5 percent of all 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, 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 the amount of your bonus, 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.

Choose the Correct PQRI Measures

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

Strategy 1: Pick manageable measures. Coders like Barbara McAneny, 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."

Master PQRI Modifiers Now

Finally, you'll have to learn to use four new modifiers to explain why your doctor didn't perform a particular quality measure. These modifiers "are the most difficult piece to understand," says Kristie Risley with Sterling Healthcare in Durham, N.C.

For instance, if you're looking at PQRI measure #61, which is for "Gastroesophageal Reflux Disease (GERD): Upper Endoscopy for Patients with Alarm Symptoms," you'll have the following modifiers to choose from when reporting category II codes 3130F or 3132F:

• 1P--Documentation of medical reason(s) for not referring for or not performing an upper gastrointestinal endoscopy

• 2P--Documentation of patient reason(s) for not referring for or not performing an upper gastrointestinal endoscopy

• 3P--Documentation of system reason(s) for not referring for or not performing an upper gastrointestinal endoscopy

• 8P--Referral for or completion of an upper gastrointestinal endoscopy was not documented, reason not otherwise specified.

Caution: 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 a physician practice 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.

Editor's note: Want to make certain you're adapting to the PQRI's documentation requirements? See Gastroenterology Coding Alert volume 9 number 10 for details.