Primary Care Coding Alert

Back again for 2010 is Medicare's incentive-driven physician quality reporting initiative (PQRI), aimed at tracking patient care through services that physicians provide. When the practice treats a Medicare patient, some PQRI dollars might be only a few codes away. If you know the basics and focus your efforts, PQRI reporting can be a breeze and a boon to your bottom line.

Check out this FAQ on the what's of PQRI.

In 2010, you can earn a bonus equal to 2 percent of your Medicare allowed charges for covered Medicare Part B Physician Fee Schedule services provided during the reporting period, if you successfully participate in PQRI.

The lowdown: There are multiple ways to qualify for the PQRI bonus, including reporting on at least three PQRI measures in 80 percent of the eligible cases, explains Alice Marie Reybitz, RN, BA, CPC, CPC-H, CHI, a coding consultant based in Belleair, Fla.

(Check out the PQRI measures list at http://www.cms.hhs.gov/PQRI/Downloads/2010_PQRI_MeasuresList_111309.pdf.)

The devil's in the details with PQRI reporting. "To properly report PQRI measures, you need to indicate a numerator and denominator," explains Eileen Lane- Coffill, CPC, PCS, senior compliance auditor at Boston's HMFP Compliance.

Breakdown: The denominator is the CPT category I code and ICD-9 (if necessary, plus patient age/gender in some cases), and the numerator is the CPT category II code(s) -- usually an F code.

Get to know the F codes, which you'll find in the Category II section in CPT 2010. The F codes represent the measure that you are reporting on; leave these off of a claim, and you cannot count it toward PQRI.

Example: The family physician (FP) provides a leveltwo E/M service to an established Medicare patient complaining of periauricular pain; final diagnosis is infective otitis externa.

This encounter qualifies for PQRI measure 92: Acute Otitis Externa (AOE) Pain Assessment: Percentage of patient visits for those patients aged 2 years and older with a diagnosis of AOE with assessment for auricular or periauricular pain," according to the PQRI measures list. Code this claim as follows to qualify for PQRI:

Denominator: 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a problem focused history; a problem focused examination; straightforward medical decision making ...) for this E/M, with 380.10 (Infective otitis externa, unspecified) appended to represent your patient's condition.

Numerator: 1116F (Auricular or periauricular pain assessed [AOE]) to represent the PQRI measure. Each measure has its own set of diagnosis requirements, where applicable. Coders are allowed to report on measure 92 for patients with a diagnosis of infective otitis externa (380.10). Some other acceptable diagnoses for measure 92 include 380.11 (Acute infection of pinna), 380.12 (Acute swimmer's ear), 380.13 (Other acute infections of external ear), and 380.22 (Other acute otitis externa).

Some PQRI measures will require a diagnosis, but others won't. Check the parameters of each PQRI measure you are considering before you report one.

Use this: Coding for PQRI without using the PQRI Tool Kit is as futile as flying a kite with no string. The link for the kit is http://www.cms.hhs.gov/PQRI/31_PQRIToolKit.asp#TopOfPage.

Bookmark this site and visit it often. From this page, you'll find that information regarding how to code each measure properly flows.

According to Kent Moore, manager of healthcare financing and delivery systems for the American Academy of Family Physicians in Leawood, Kan., here are some of the PQRI shakeups that affect FP coders:

CMS added a minimum patient sample of 15 patients (for full-year reporting) or 8 patients (for half-year reporting) for one individual measure or measures group. CMS simplified registry-based reporting by removal of the requirement to report consecutive patients (i.e., reporting of patients in order seen). "Physicians are able to successfully report on any patients who meet the numerator and denominator criteria for the measure or measures group being reported during the reporting period, regardless of date seen," explains Moore. CMS created a large group practice (i.e., more than 200 eligible professionals) PQRI reporting option. "Large groups may report and receive a bonus based on the group's overall PQRI success rather than by individual physician or provider. If successful with groups of this size, CMS may open this option to smaller group practices in the future," relays Moore CMS created electronic health record (EHR)-based reporting as an option in 2010.

Silver lining: Though the above changes to PQRI are all FP-relevant, that's all that's new this year. "I am not aware of any major changes for FPs related to the PQRI measures themselves," relays Moore.

Consider this detailed PQRI scenario from Moore:

Example: The FP sees an established 66-year-old Medicare patient for a follow-up visit to check on the patient's type II diabetes mellitus. During a level-three E/M, the FP notes that the patient's most recent hemoglobin A1c is 6 percent.

This encounter qualifies for PQRI measure 1: Diabetes Mellitus: Hemoglobin A1c Poor Control in Diabetes Mellitus. On the claim, report the following:

Denominator: 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity ...) with 250.00 (Diabetes mellitus without mention of complication; type II or unspecified type, not stated as uncontrolled) appended to the service

Numerator: 3044F (Most recent hemoglobin [HbA1c] A1c level less than 7.0% [DM]) to represent the correct PQRI measure.

You can come up with a list of three measures that the practice will focus on for PQRI. With the diversity of family medicine practices, there are a lot of measures your FP might focus on, Moore observes.

A few PQRI measures that your practice might be able to report on include:

• 3 -- Diabetes Mellitus: High Blood Pressure Control in Diabetes Mellitus;

• 6 -- Coronary Artery Disease (CAD): Oral Antiplatelet Therapy Prescribed for Patients with CAD;

• 39 -- Screening or Therapy for Osteoporosis for Women Aged 65 Years and Older;

• 41 -- Osteoporosis: Pharmacologic Therapy for Men and Women Aged 50 Years and Older;

• 51 -- Chronic Obstructive Pulmonary Disease (COPD): Spirometry Evaluation;

• 52 -- Chronic Obstructive Pulmonary Disease (COPD): Bronchodilator Therapy;

• 53 -- Asthma: Pharmacologic Therapy;

• 110 -- Preventive Care and Screening: Influenza Immunization for Patients ? 50 Years Old;

• 112 -- Preventive Care and Screening: Screening Mammography;

• 113 -- Preventive Care and Screening: Colorectal Cancer Screening;

• 114 -- Preventive Care and Screening: Inquiry Regarding Tobacco Use; and

• 154 -- Falls: Risk Assessment.