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Medicare Compliance & Reimbursement

QUALITY:

Thousands Of Dollars Could Depend On A Few Extra 'G' Codes

Published on Wed Feb 21, 2007

Make sure you know which quality measures apply.

With your practice's margins narrower than ever, an extra 1.5-percent boost at the end of the year could be a life-saver. But to get that extra money, you'll need to be on your toes. 

To receive an extra 1.5 percent of all your payments for the last six months of this year, your doctor needs to report 80 percent of the time on measures that apply to him or her, officials from the Centers for Medicare & Medicaid Services (CMS) clarified at the March 6 physician Open Door Forum. 

CMS officials also explained that:

· Your doctor needs to report only three quality measures per visit, even if 10 or 20 quality measures apply to that patient, CMS officials said. For some specialties, only one or two quality measures may apply to all of their patients. So if those doctors report on those one or two quality measures, they'll receive the full 1.5-percent bonus.

But doctors who report on fewer than three measures may have to validate that they don't have any other applicable measures, CMS officials told the March 5 Practicing Physicians Advisory Council meeting.

· By law, CMS can keep tweaking the list of code measures that are included in the Physician Quality Reporting Initiative (PQRI) right up until the July 1 start date. That could give your practice and your vendors no leeway at all to get set up for the program before the deadline. But officials promised they would finalize the codes well before the start date.

· How will you know whether a particular measure applies to your doctors? Partly by looking at the descriptors of the codes and partly by the situation, CMS officials said.

For example: If you're billing an office visit for a patient with the diagnosis of diabetes, then the measure of whether your doctor did a hemoglobin A1C would apply, officials said.

Warning: If your doctor reports a measure once, then CMS will assume afterwards that that measure applies to your doctor. So if your doctor reports a particular measure by mistake once, and then never reports it again, CMS could assume your doctor hasn't been participating properly.

· If a quality measure has both a "G" code and a Category II code, you can use either one to report it, CMS officials explained. Over time, CMS would like to move the program over to all Category II codes, but that may not be possible.

· Your doctor may have to meet an average number of payments or patients to receive the full 1.5-percent bonus, even if he or she reports all the quality measures, CMS told PPAC.

Also, the money for this bonus is a separate fund for 2007. But if the program continues in 2008, then the money may come out of general physician payments--which could mean doctors who don't participate in the PQRI will end up receiving less money.

· A large physician group that participates in the program may not be able to tell how many quality measures its individual physicians reported on. That's because the group may receive payment based on its group tax ID number. But CMS is working on a way to modify its software to issue reports by each individual physician's National Provider Identifier (NPI) instead of by group tax ID, according to the Physician Regulatory Issues Team.

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