Otolaryngology Coding Alert

Take a look at the new Category II codes before you shun 2 percent bonus.

Does your ENT treat people with earaches? Do any of your patients smoke?

Well, you might be interested -- possibly for the first time -- in CMS's Physician Quality Reporting Initiative (PQRI). New Category II codes for flu shots, tobacco counseling, and treatment of bronchitis and otitis could bring Medicare's participation bonus within reach for ENTs- offices.

To receive the bonus, your physician must report on the selected measures most applicable to your practice. Otolaryngologists should select at least three measures in an attempt to receive the bonus, which has been bumped to 2 percent for 2009, says Barbara Colburn, president and CEO of Total Health Care Solutions in Ocala, Fla.

You don't have to register for the PQRI, experts say. You just have to start reporting category II codes on your claims. The category II codes should be on the same claim as the visit they apply to. Once you begin to report a specific measure, you must report that measure for the patients to whom it applies throughout the reporting period. (Learn about the reporting options at www.cms.hhs.gov/PQRI/Downloads/2008PQRIalterrptperiods.pdf.)

Example: Check out this PQRI scenario that could play out in your otolaryngology office:

Your practice sees a lot of otitis patients and decides to report on measure 91, "Acute Otitis Externa (AOE): Topical Therapy." Every time a Medicare patient comes in with otitis, you will examine the documentation to see whether the ENT prescribed a topical preparation.

If the physician did, you will add 4130F (Topical preparations [including OTC] prescribed for acute otitis externa [AOE]) to the claim.

If the physician did not prescribe long-term control medication or an acceptable alternative, you will explain why using a modifier.

You get the bonus for reporting, not performing: Even if the otolaryngologist doesn't perform one of the measures, you should still report 4130F for an eligible case. You just use the appropriate PQRI modifier:

- 1P -- Performance measure exclusion modifier due to medical reasons

- 2P -- Performance measure exclusion modifier due to patient reasons

- 3P -- Performance measure exclusion modifier due to system reasons

- 8P -- Performance measure reporting modifier -- action not performed, reason not otherwise specified.

History: In March 2007, The Centers for Medicare and Medicaid Services (CMS) established the PQRI, a voluntary program in which physicians collected and reported their practice data on a set of performance measures between July and December 31, 2007.-The program is still voluntary, but it's considered a precursor to a mandatory pay-for-performance (P4P) program.-

All carrot, no stick: Medicare does not penalize doctors for poor performance. PQRI "offers Medicare providers nationwide a low-risk opportunity to gain experience with reporting procedures likely to be incorporated into P4P reimbursement schemes," wrote Jonah-Stulberg, MPH, in the January-March 2008 issue of Quality Management in Health Care, a peer-reviewed journal.

Not everyone's excited about the federal government getting in the business of grading physicians- performance. "When payers actually begin practicing medicine and surgery, then we can talk," says Dianna Hofbeck, RN, CCM, forensic examiner-medical documentation for Amish-Mennonite Affordable Healthcare Ministry and New Jersey chairperson of the National Patient Advocate Foundation.

Hofbeck suggests physicians might want to check into PQRI to see what Medicare is up to. She calls it "a--forewarned is forearmed- type of strategy."