Urology Coding Alert

Key: Educate your staff and perform a test run soon

Your time to prepare for the Physician Quality Reporting Initiative (PQRI) is quickly running out. So now is the time when you need to figure out how to bill enough category II quality codes to receive the 1.5 percent bonus from Medicare.

Bad news: 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, and you will be limited to a payment cap determined by the number of quality measures you do report.

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.

The bonus will apply to all allowable charges, including deductibles and copayments. Bonus calculations will not include physician laboratory or physician-administered drug charges, and there will be no beneficiary co-insurance requirement for quality measures you report. On the other hand, as indicated above, CMS will apply a "cap" to the bonus for doctors who do not report a sufficient number of quality measures, and there will be no appeal process for physicians to question their bonus payments.

Good news: Let our expert guidance set you on the right path to ensure your urologist gets the bonus money that he deserves.

Focus on Urology Quality Measures

Your first step with PQRI is to decide which quality measures to use. CMS has posted a list of the 74 quality measures, along with detailed specifications, at www.cms.hhs.gov/pqri. You should consider which conditions your practice treats and the type of care your practice provides: preventive, chronic or acute.
 
Key: Choose measures that have a large impact on your practice's quality improvement. If you pick three quality measures that you only report on infrequently, you risk coming under the "cap" on bonus payments, and you won't receive the full 1.5 percent bonus payment.

For urology, you'll likely want to home in on the following three measures, says Morgan Hause, CCS, CCS-P, privacy and compliance officer for Urology of Indiana LLC, a 31-urologist, two-urogynecologist practice in Indianapolis:

• #48--Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older
• #49--Characterization of Urinary Incontinence in Women Aged 65 Years and Older
• #50--Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older.

Associate Measures With Correct CPT Codes

To help you prepare, CMS released specifications at www.cms.hhs.gov/PQRI/Downloads/Specifications _2007-02-04.pdf. For each quality measure, the document lists the CPT codes and diagnosis codes that go with it. If you report a particular CPT and ICD-9 code together, you can see if the quality measure applies. Then you report on test results or other measures using Category II or "G" codes.

If the measure doesn't apply, you can use modifiers 1P (Medical reasons), 2P (Patient reasons) and 3P (System reasons) to explain why you didn't apply it. Alternatively, you can apply modifier 8P (Unspecified reasons). Keep in mind, however, that the measurement specs for urinary incontinence do not list 2P or 3P as applicable modifiers, Hause says.

Pointer: If more than one physician treats the same patient, each doctor can report on the same quality measure for that patient, CMS officials said. You should only report on quality measures that fit with your urologist's specialty and with particular eligible patients. But if your doctors provide care outside of their specialty, such as managing a patient's other problems, you can report other quality measures. But this is unlikely in a urology practice.

You need to report some measures only once a year, so you don't have to keep including them on each code after you report them the first time. But for measures that you're supposed to report once per year, you won't suffer any penalty for reporting them more than once by mistake.

Tip: When you're figuring out which claims to match up with the quality reporting codes, you should look at both primary and secondary ICD-9 diagnosis codes, experts say.

Determine Problem Spots Before the Deadline

You should be modifying your office and billing systems, CMS official Susan Nezda said during an April 19 conference call on the PQRI. You need to figure out which role each member of your team will play in the reporting process, and educate all of your staff. You can use tools like worksheets, encounter forms and screen templates to capture the data.

Important: You should test your systems before the July 1 start date to make sure your venders are up to snuff, Nezda said. Verify that your practice management or billing system can "bill out a zero charge associated with new HCPCS codes," Hause says. Also verify that your clearinghouses will accept these new HCPCS codes and modifiers and pass them on to the carriers you work with, he adds. "For systems that cannot do '0,' the guidelines allow for a nominal amount, such as 1 cent."

You'll report quality measures and CPT category II codes on the same CMS-1500 form you use to bill for your clinical services. Enter a "0" charge in box 24F on the 1500 form for these quality measure codes.

Deadline: CMS will consider your quality reporting only for claims that reach the National Claims History (NCH) file by Feb. 29, 2008. You can't resubmit claims just to add the quality-reporting codes, nor can you submit the quality-reporting codes by themselves on a separate claim.

Other quality measures that urologists may report include:

• #20--Perioperative Care: Timing of antibiotic prophylaxis--ordering physician
• #21--Perioperative Care: Selection of prophylactic antibiotics--first- OR second-generation cephalosporin
• #22--Perioperative Care: Discontinuation of prophylactic antibiotic (noncardiac procedures)
• #23--Perioperative Care: Venous thromboembolism (VTE) prophylaxis (when indicated in all patients)
• #30--Perioperative Care: Timing of prophylactic antibiotic--administering physician.