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Pulmonology Coding Alert

Get the Truth on 4 PQRI Myths

Published on Mon Sep 24, 2007

Reporting the voluntary measures might financially benefit your practice

Before you let enrollment and applicability concerns deter you from participating in CMS' Physician Quality Reporting Initiative (PQRI) program, find out just what it entails and how it affects pulmonology practices.

If you want to be eligible for Medicare's 1.5 percent bonus, start reporting quality indicators immediately. Practices whose quality reporting meets the specified standards are eligible for up to 1.5 percent of their total Medicare billings during July 1 to Dec. 31. To receive the bonus, your doctor must report on the selected measures most applicable to your practice. Pulmonologists should select at least three measures in an attempt to receive the total 1.5 percent reimbursement.


Myth 1: Since we didn't enroll, we can't participate

Reality: 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. Once you begin to report a specific measure, you must report that measure for the patients to whom it applies throughout the entire six-month period.

Check out these two examples of PQRI reporting scenarios that could play out in your pulmonology office.

Example 1: Your practice sees a lot of asthma patients and therefore decides to report on measure 53. Then, every time a Medicare patient comes in with asthma, you will examine the documentation to see whether the pulmonologist prescribed either the preferred long-term control medication (inhaled corticosteroid) or an acceptable alternative treatment.

If the physician did, you will add 4015F (Persistent asthma, preferred long-term control medication or an acceptable alternative treatment prescribed) and 1038F (Persistent asthma [mild, moderate or severe]) to the claim. If the physician did not prescribe long-term control medication or an acceptable alternative, you will explain why using the codes listed in Figure: Myth 1: Code Chart.

Example 2: Suppose your practice sees a lot of patients with community-acquired bacterial pneumonia (CAP) and therefore decides to report on measures 56 through 59.

Then, every time a patient comes in with CAP, you will examine the documentation to see whether your physician checked the patient's vital signs. If the physician did, you will add CPT code 2010F to the claim. If the physician didn't check the vital signs, you will still report 2010F, but you'll also attach a modifier explaining why the physician did not perform the check.

For example, modifier 1P means the doctor didn't record the patient's vitals for medical reasons.

Similarly, you will report 3028F, with or without a modifier, to note whether the pulmonologist checked the patient's oxygen saturation results. And you'll report 2014F for whether the doctor checked the patient's mental status, and 4045F for whether the doctor prescribed an "appropriate empiric antibiotic."


Myth 2: Hearing others' tales might make us join in

Catch: Although you can start reporting Category II codes at any time, if you start too long after the July 1 launch date, you probably won't report enough quality codes to make the 1.5 percent bonus, CMS officials have warned. In this case, you may be limited to a payment cap determined by the frequency of reported quality measures.

How it works: Every physician who reports on quality measures at least 80 percent of the time that they apply to his eligible patients will receive a bonus next year. The bonus will consist of up to 1.5 percent of the total allowable amount each doctor billed Medicare from July 1 to Dec. 31, 2007.

Because some measures have a variable reporting rate (e.g., annually, biannually, every visit), CMS will apply a "cap" to the bonus for doctors who do not report as frequently as others, and there will be no appeal process for physicians to question their bonus payments.


Myth 3: No measures apply to our practice

Of the 74 PQRI measures, there are 10 quality reporting measures that could apply to pulmonology practices:

  • 46 -- Medication reconciliation
  • 51 -- Chronic obstructive pulmonary disease (COPD): spirometry evaluation
  • 52 -- Chronic obstructive pulmonary disease (COPD): bronchodilator therapy
  • 53 -- Asthma: pharmacologic therapy
  • 56 -- Vital signs for community-acquired bacterial pneumonia
  • 57 -- Assessment of oxygen saturation for community-acquired bacterial pneumonia
  • 58 -- Assessment of mental status for community- acquired bacterial pneumonia
  • 59 -- Empiric antibiotic for community-acquired bacterial pneumonia
  • 64 -- Asthma assessment
  • 66 -- Appropriate testing for children with pharyngitis.

Tip: Medicare has published a "PQRI Code Master," which is an Excel spreadsheet of ICD-9 diagnosis codes and CPT codes, along with the measures that apply to them. This could be helpful in picking which measures to report, says Eric Sandhusen, CHC, CPC, director of reimbursement, HIPAA and fiscal compliance with Columbia University department of surgery.

Check it out online: Download this and other tools found in the PQRI Tool Kit from www.cms.hhs.gov/pqri.


Myth 4: Financial incentive minimal for practice

Reality: You could still receive bonus payments on the measures you choose to report even if you have a limited number of eligible claims, says Karla M. Westerfield, a business manager in Cheyenne, Wyo. CMS is reimbursing "based on national volume per reportable measure, not just your office or specialty. As long as you report every time it applies," Medicare will reimburse you accordingly.

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