Eli's Rehab Report

If you're not sure which measures apply to your discipline, CMS doesn't spell it out in black and white for each measure. With that in mind, simply treat the measures as you would a CPT code asking, "Does it fall within my scope of practice?" says Ellen Strunk, PT, MS, GCS, clinical consultant for Restore Management Services in Pelham, Ala. If it does, see if CMS lists a CPT code with the measure that you would normally report.

You can let CMS know you're performing a quality measure by entering its "quality data code" as a separate line item on the claim form. Mark it with a charge of $0.00 or $0.01 if your billing software doesn't accept zero charges, says Gayle Lee, JD, director of regulatory affairs for the American Physical Therapy Association (APTA). (See the chart on page 27 for more details on which quality data codes pertain to each measure.)

The catch: CMS will not accept a quality data code unless it's linked to a CPT code -- and that CPT code has to be on CMS' list of CPT codes that link to the measure.

For example, an OT performs a pain assessment prior to administering therapeutic exercise. He reports the appropriate quality data code on the claim form -- G8440 (Documentation of pain assessment [including location, intensity and description] prior to initiation of treatment or documentation of the absence of pain as a result of assessment). In addition, that claim form needs the regular CPT code the OT would already be reporting for that patient encounter, such as 97003 (Occupational therapy evaluation) -- which is indeed on CMS' eligible CPT code list for the pain assessment measure.

Tip: For rehab providers, "the CPT code that links to the quality data code is almost always the PT [or OT] eval/re-eval," Lee says.

Watch for: Many quality measures indicate that they need to occur at "each visit," which is confusing for therapists who may see patients multiple times a week. For example, it wouldn't make sense to ask patients about their current medications three times a week. "So CMS clarified that by 'each visit,' it means 'each visit where the initial evaluation happened,' " Lee tells Eli. And if you're linking the quality data code with an eval or re-eval CPT code, that's what your claim will indicate anyway.

Some good news is that the "1.5 percent bonus" applies to total charges paid by Medicare -- not just those that apply to the quality measures, APTA confirms with Eli.

And the rules are pretty much the same as last year when it comes to collecting your bonus from CMS. That is, you must perform -- and document -- a quality measure 80 percent of the time it's applicable. (The chart on page 27 indicates the applicable patient population.) The main thing that's changed is that now your practice must successfully report on at least three quality measures to qualify for the bonus, Lee says.

And of course, when you report the measures, just like any other billing claim, you must consider all of the measure's specifications and justify that you met the requirements in your documentation.

If you work in a SNF, home heath, CORF, hospital, or any other rehab setting that isn't eligible for PQRI, don't despair. The reason you can't participate in the PQRI is that your claim form doesn't have a place for an individual therapist's NPI -- which is necessary for reporting quality measures. But CMS is working on a solution, Lee says, looking hopefully ahead to 2009.

Meanwhile, consider incorporating these measures into your practice and documenting them in your own records. Why? "When CMS does fix the glitch, it might make the PQRI bonus retroactive for providers who couldn't participate before," Strunk says, in reference to arguments several organizations have made about the original statute. "And if that's the case, you'll want to have a record of that." But you should also ask yourself if the cost of implementing and tracking the measures is worth the bonus you might receive, Strunk says.

Note: For more information on PQRI, particularly the Screening for Future Falls Risk measure, see Physical Medicine Rehab & Coding Alert, Vol. 9, No. 2. Also, visit the CMS Web site at http://www.cms.hhs.gov/PQRI. Click on "Measures/Codes" on the left, then click on the second link under "Downloads."