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Part B Insider (Multispecialty) Coding Alert

PQRI:

Cardiology Association Urges Physician Involvement for Successful PQRI Implementation

Published on Mon Feb 23, 2009

Plus: If your claim has a zero dollar charge, don't expect your PQRI bonus to increase.

If your physician hasn't decided whether or not to get involved in the PQRI claims process, you can't expect to see the maximum return. That's the word from a March. 18 American College of Cardiology/CMS open door forum offering advice on improving PQRI success.

Don't look for this measure: Coding professionals that are scratching their heads looking for measure 7 (Beta-blocker therapy for CAD patients with prior MI) should look no further.

"You'll notice that measure 7 is gone," said John Schaeffer, MD, president of the North Ohio Heart Center in Avon, Ohio, on the call. "Measure 7 has been removed because it turned out to be very, very difficult," Schaeffer said. "It had one of the highest failure rates. In the range of 85 percent of the time, we were not reporting that correctly, probably because it required two ICD-9 codes. So CMS decided to remove this from the claims base."

However, Schaeffer said, you can still use the following cardiology measures:

• Measure 5 -- ACE or ARB therapy prescribed for heart failure patients with LVSD

• Measure 6 -- Anti-platelet therapy prescribed for CAD patients

• Measure 8 -- Beta-blocker therapy prescribed for heart failure patients with LVSD

• Measure 118 -- ACE or ARB therapy prescribed for CAD patients with diabetes or LVSD

• Measure 152 -- Lipid panel for CAD patients.

Tip: You must report the CPT Category II quality data codes on the same claim as the ICD-9 and E/M codes (which supply the measure denominator) to qualify for claims-based submission, Schaeffer said.

Keep in mind: In prior years, the practices that took careful, strategic approaches to PQRI were more successful than those who just reported a code on the claim and forgot about it, said Sylvia Publ, MBA, RHIA, senior quality advisor in CMS' office of clinical standards of quality, during the call.

Remember: If your claim has a zero dollar charge, the claims-based PQRI system will reject it, Publ says.

Increase success odds: To ensure that your PQRI has a better shot at succeeding, you should establish a PQRI team that includes physicians nurses, coders, billers, and administrators, Schaeffer says. In addition, you should analyze the specifics of the PQRI program, and ensure that you're billing accurate diagnoses.

"Physician involvement is mandatory, payback is obvious, there's an economic return, and of course the most important thing is we get better patient care and better documentation," Schaeffer says.

To review the complete presentation materials for the March 18 ACC call, including documentation guide templates, visit www.acc.org/advocacy/advoc_issues/medicare_pqri031209.cfm.

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