Medicare Compliance & Reimbursement

Alert: Your physician may be meeting quality measures, but not documenting.

Practices are gearing up to participate in the Physician Quality Reporting Initiative (PQRI). And they're finding ways to adapt to the PQRI's requirements--you can learn from their examples.

Encounter forms: "We are adding the codes to our encounter forms, including the modifiers with instructions to use them if a patient is to be excluded," says Bob Lloyd with Mid-State Cardiology in Nashville, TN.

Note: Your physician may already be doing the things that PQRI asks about, but not documenting them. For example, one OB/Gyn physician who performs several surgeries a week was already performing prophylactic antibiotic therapy, prophylactic thrombosis and deep vein thrombosis, says Rachel Morales with Harrington Cancer Center in Amarillo, TX. But the OB/Gyn wasn't documenting that he was doing these things, says Morales. "Now he goes out of his way to make sure it's documented in the surgical report," she adds. "All I have to do is extract the information."

For a hospital-based practice, it's important to obtain documentation directly from the hospital, notes Donna Allshire, operations director with Professional Emergency Physicians in Fort Wayne, IN.

Reference sheet: Allshire's staff created a special reference sheet, listing diagnosis codes along with the measures that go with them. At first, the coders will turn every Medicare chart sideways or pull it out of the stack. Then the coders can look through specifically for places to add the PQRI measures. "I'm sure for the first month this will slow our coding staff down and their productivity will drop," says Allshire. "But we are hoping this will improve as everyone gets use to the new measures."

Morales is creating an attachment to her practice's fee slips with measures listed on them. This will remind the physicians to document any measures and then mark them on the attachment. She used 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").

You need a separate space for the physician to note whether he or she 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, TX. 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 (also available at: www.cms.hhs.gov/pqri). This could be helpful in picking which measures to report, says Eric Sandhusen, director of reimbursement, HIPAA and fiscal compliance with Columbia University Dept. of Surgery.

Check your software: Some programs, such as T-System Inc.'s T SystemEV program for emergency physicians, provide your physician with an "addendum" to capture the quality measures, notes Kristie Risley with Sterling Healthcare in Durham, NC.

Tip: Work with your software vendor to make sure your system can accept the PQRI codes as valid, Risley advises. Because these codes have no payment amount, you could try listing them as having a reimbursement of $0.01 so your software can accept them. Also, your system should flag certain ICD-9 codes as being pertinent to a particular quality measure you're capturing.

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," notes Risley.

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

Solution: If you can't figure out why the doctor didn't perform a particular quality measure, you can always add the 8P modifier, notes Sandra Pinckney, coder at Certified Emergency Medicine Specialists in Grand Rapids, MI. But in that case, Pinckney will send the chart back to the physician asking for more information, to limit the use of the 8P modifier.