Ob-Gyn Coding Alert

Experts warn that learning modifiers might be the trickiest part If your ob-gyn

If your ob-gyn practice wants to participate in the Physician Quality Reporting Initiative (PQRI), 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

What it is: 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 Dec. 31, 2007, according to CMS.

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 Medicare patients with urinary incontinence and therefore decides to report on measure #48: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older.

Then, every time a 65-year-old or older patient comes in, you will examine the documentation to see if your physician assessed whether the patient had urinary incontinence within 12 months.

If the physician did, you will add code 1090F (Presence or absence of urinary continence assessed) to your claim.

Master Your PQRI Modifiers

If the physician didn-t, you-ll have to learn to use four new modifiers to explain why. These modifiers -are the most difficult piece to understand,- says Kristie Risley with Sterling Healthcare in Durham, N.C.

If the physician did not assess the patient for urinary incontinence because of medical reasons (for instance, the physician already assessed the patient for this measure, or it is contraindicated in this patient's case for some reason), you-ll append modifier 1P (Documentation of medical reason[s] for not assessing for the presence or absence of urinary incontinence) to 1090F. Your physician must document this fact in the medical record to use this modifier.

If the physician did not assess the patient for urinary incontinence for an unknown reason, you-ll add modifier 8P (Presence or absence of urinary incontinence not assessed, reason not otherwise specified) to 1090F. But in that case, send the chart back to the physician asking for more information to limit your 8P modifier, says Sandra Pinckney, CPC, coder at a physician specialist practice in Grand Rapids, Mich. Using 8P means the physician is not taking credit for that service.

Reap the Benefits

Result: If your quality reporting meets the 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 at least three measures at least 80 percent of the time in which they apply, but you can report more than one measure per claim if they applied to the patient at that visit.

Recipe for success: Remember that how many measures may apply to your patients doesn't matter, says Robert La Fleur, MD, a physician and president of Medical Management Specialists in Grand Rapids, Mich. You can report only the minimum of three during the time period or more if they apply. The American College of Obstetricians and Gynecologists (ACOG) has suggested that quality measures regarding perioperative care (#20, 21, 22 and 23), osteoporosis screening/therapy (#39, 41 and 42) and stress urinary incontinence (#48, 49 and 50) would pertain to most ob-gyn practices.

What's important: You just have to report at least three measures during the reporting period at least 80 percent of the time when that measure applies to any patient seen by the physician. And you must include the rendering physician's national provider identifier (NPI) number with the claim.

Keep in mind: There's a cap that might reduce your bonus amount 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. So if you report on quality measures only a few times, you won't get the full 1.5 percent bonus.

Capture PQRI Through Documentation

Practices are gearing up to participate in 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, CEO of a physician practice in Nashville, Tenn.

Note: Your physician may already be doing the things that PQRI asks about but not documenting them. Inform your physicians of what they need to document in their reports by looking at the PQRI measures your practice has decided to take on, so all you need to do is extract the information.

For a hospital-based practice, -it's important to obtain documentation directly from the hospital,- says Donna Allshire, operations director with a physician practice in Fort Wayne, Ind.

Reference sheets: 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,- Allshire says. -But we are hoping this will improve as everyone gets used to the new measures.-

Also, you can create an attachment to your 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. Use 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-).

Watch out: You need a separate space for the physician to note whether he performed these quality measures -- even if the information is already in the chart somewhere, says Jackie Davis-Willett, CHMBE, president and CEO of TERM Billing in Mansfield, Texas.

Note: Medicare finally published a -PQRI Code Master,- which is an Excel spreadsheet of ICD-9 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, MPH, CHC, CPC, director of reimbursement, HIPAA and fiscal compliance with Columbia University department 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, Risley says.

-We-re doing the PQRI quality reporting through our electronic medical records. The system looks for certain diagnoses and criteria and checks them against the medication lists and contraindications,- says Jennifer Crowell, CPC-EMS, hospital coordinator at a Spokane physician practice in Wash.

In other words, the system first will determine whether the patient has Medicare and, if yes, then compare the CPT codes and ICD-9 codes with those included in Measures 48 through 50, which are:

• Measure #48: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older
• Measure #49: Characterization of Urinary Incontinence in Women Aged 65 Years and Older
• Measure #50: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older.

Tip: Work with your software vendor to make sure your system can accept the PQRI codes as valid, Risley says. 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.