Medicare Compliance & Reimbursement

Thanks to PQRI's renewal, you've got a shot at an end-of-year bonus from CMS for reporting on certain measures, provided you can make the approved diagnosis and CPT link.

The basics: Medicare recently renewed the Physician Quality Reporting Initiative for 2008. According to CMS, "Those who satisfactorily report quality-measures data on claims for services furnished Jan. 1 through Dec. 31, 2008, will earn a single consolidated incentive payment in mid-2009."

According to CMS, the incentive payment will be 1.5 percent of total allowed charges for covered services provided between Jan. 1 and Dec. 31, 2008. "Incentive payments earned will be paid to the Taxpayer Identification Number (TIN) under which the incentive-earning professional submitted PQRI claims," CMS says.

To get an idea what to report, how to report it, and how to make the whole PQRI process more palatable for coders and physicians, check out this PQRI coding primer.

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, says Chris DuBois, CPC, coding and compliance coordinator with Western Massachusetts Physician Associates in Holyoke. The bonus will apply to all allowable Medicare charges, including deductibles and copayments.

And for now, PQRI scoring is tied only to reporting, but this is the time to get your systems in order. Ultimately, CMS envisions tying payment to successfully performing these measures.

The current list of measures contains many entries that might be relevant to your medicine practice, but it will depend on your particular patient mix.

Internal medicine practices, for example, should check measures associated with diabetes, hypertension, coronary artery disease (CAD), chronic obstructive pulmonary disease (COPD), and screening services.

Best bet: Find the three measures your physician reports the most and focus on those.

And if the practice satisfies the PQRI requirements for at least 80 percent of its patients on three measures, it is eligible for the bonus, says Dru Heffington, business manager at Cool Springs Internal Medicine and Pediatrics Clinic in Brentwood, TN.

For example, if your physician treats a lot of diabetic patients, you might focus on "Measure 1: Hemoglobin A1c Poor Control in Type 1 or 2 Diabetes Mellitus."

For accurate PQRI reporting, you'll need to report the proper diagnosis and CPT code for the service, and 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.

"Each PQRI measure has specific CPT and ICD-9 requirements," Heffington says. If an encounter meets these requirements, and you choose the proper category II code, you can file a quality report.

For example, here are Medicare's requirements for Measure 1: Hemoglobin A1c Poor Control in Type 1 or 2 Diabetes Mellitus:

"Reporting description: Percentage of patients aged 18 through 75 years with diabetes mellitus and an applicable CPT Category II code reported a minimum of once during the reporting period.

"Performance description: Percentage of patients aged 18 through 75 years with diabetes mellitus who had most recent hemoglobin A1c greater than 9.0 percent."

Coding example: You are reporting on Measure 1. According to Medicare's 2008 Physician Quality Reporting Initiative Specifications Document, "This measure is to be reported a minimum of once per reporting period for patients with diabetes mellitus seen during the reporting period."

If your provider's documentation supports you reporting this measure, you'll first need to report the appropriate encounter code.

Also, for Measure 1, the patient must have one of these diagnoses: 250.00-250.93, 648.00-648.04.

The Measure 1 reporting requirement is limited to cases in which any of these service codes and ICD-9 codes are included on the same claim. When Medicare sees a combination of the above codes, it will be looking for a PQRI report.

Suppose the physician provides a level-four E/M for an established patient who has type II diabetes and a most recent hemoglobin A1c of 10.0 percent.

On the claim, report 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which re-quires at least two of these three key components: a detailed history; a detailed examination; medical decision-making of moderate complexity) for the E/M linked to 250.02 (Diabetes mellitus without mention of complication; type II or unspecified type, uncontrolled) for the patient's diabetes.

To qualify the above encounter for PQRI, you'll next need to choose a category II code.

According to Medicare, you should include 3046F (Most recent hemoglobin A1c level greater than 9.0% [DM]) on the claim to meet PQRI standards.

(Note: The PQRI codes are listed online on the CMS Web site at http://www.cms.hhs.gov/pqri.)

In a nutshell: For accurate Measure 1 reporting, this example's claim should contain 99214 linked to 250.02 and 3046F.

To help physicians and coders comply with PQRI, the AMA posted several data collection sheets that you can use at your practice to keep up with Medicare's requirements. Check out the Measure 1 sheet at http://www.ama-assn.org/ama1/pub/upload/mm/370/wrksht_01_08.pdf.