Medicare Compliance & Reimbursement

Improve communication between clinical and admin sides -- or lose out.

While your physicians are noting whether or not they provided aspirin to patients as suggested by quality guidelines, you might want to save some aspirin for yourself. Medicare's quality reporting project is likely to give you a major headache as you struggle to understand its complexities in time for the July 1 start date.

"This program is going to be arcane and difficult to implement," says Barbara McAneny, a physician with New Mexico Oncology in Albuquerque. But with reimbursement cuts, her practice can't afford to pass up another 1.5 percent in reimbursement.

The basics: You don't have to register for the program. You choose which quality measures you're going to start reporting on, and just start reporting them. Important: Once you've reported a particular quality measure once, Medicare will expect you to keep reporting on it at least 80 percent of the time where it applies.

Reporting on quality measures correctly will mean working on communication between your clinical staff and your administrative people, Centers for Medicare & Medicaid Services (CMS) officials warned.

Step 1: First, you'll have to identify which patients and visits qualify for the quality reporting.

Step 2: Then, your physician must document in the medical record whether he or she followed a particular quality guideline. CMS won't tell you how, or where, this documentation should appear. You could use a checkbox or an area on your encounter form.

Step 3: After that, you have to translate that quality information over to your claims submission process, so you can submit the correct code, stating whether or not the physician followed the quality guideline. (Whether the answer is yes or no, you get credit for reporting.)

The biggest hurdle will be prodding software vendors to update systems to handle this program, McAneny predicts. She's reluctant to spend the money on upgrades before she knows whether the program will be permanent.

More details: CMS officials also revealed specifics about the quality-reporting program:

· You don't have to be a Medicare-participating physician to participate in the program.

· CMS will post detailed instructions about how to report the 74 measures on the Web long before the July 1 deadline.

· When you use the "G" codes (or Category II codes in some cases) to report on the quality measures, you must record a charge of $0.00 with those codes.

· You must report the quality codes on the same claim as the payment codes for that service.

· The analysis of whether you reach the 80-percent requirement for the measures you report will be based on each individual provider's NPI. So if some of the physicians in a group practice are more diligent about [...]