A Physiatrists Guide to the Centers for Medicare and Medicaid Services Physician Quality Reporting I

1
A Physiatrists Guide to the Centers for Medicare
and Medicaid Services Physician Quality
Reporting Initiative
2
PQRI Introduction

• This presentation was current at the time it was
  published or uploaded onto the Web. Medicare
  policy frequently changes so links to the source
  documents have been provided within the document
  for your reference.
• The Academy makes no guarantee the information
  is error-free and will bear no responsibility or
  liability for the results of the use of this
  guide. This presentation is a general guide that
  explains certain aspects of the PQRI program, but
  is not a legal document.
• The aforementioned information is copied from
  CMS website

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PQRI Introduction

• The intent of this presentation is to assist
  physiatrists who elect to participate in the
  Centers for Medicare and Medicaid Services (CMS)
  Physician Quality Reporting Initiative (PQRI).
  Although the Academy has made reasonable attempts
  to assure the accuracy of the information, the
  ultimate responsibility for the correct
  submission of claims and response to any
  remittance advice lies with the provider of
  services.
• The aforementioned information is copied from
  CMS Website

4
PRQI Introduction

• PQRI program is part of the Tax Relief and
  Healthcare Act (TRHCA) enacted by Congress in
  December 2006. Originally, the program was
  called the Physician Voluntary Reporting Program
  (PVRP) in which physicians voluntarily submitted
  data on 16 evidence-based quality measures in
  2006.

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PQRI Introduction

• In March 2007, CMS transitioned from the PVRP
  program to the PQRI program and published 74
  quality measures for health care professional to
  utilize for 2007. Physicians and other eligible
  health care professionals have an opportunity to
  receive a bonus equal to 1.5 of allowable Part B
  charges for all covered professional services
  through submission of claims data.

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PQRI Introduction

• PQRI reporting will focus on quality of care
• Evidence-based measures developed through a
  collaborative process
• Potential to receive financial incentive by
  reporting data
• Improvement in care through measurement
• Reporting is the first step towards
  pay-for-performance
• The aforementioned information is copied from
  CMS website

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PQRI Introduction

• Physicians, physical therapists and clinical
  social workers are just a few of the eligible
  health care professionals that can elect to
  participate in the PQRI program
• To view the complete list of eligible health care
  professionals, please click on the following
  link www.cms.hhs.gov/PQRI

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PQRI Introduction

• Eligible health care providers can participate in
  the PQRI program by submitting performance
  measurement data on three or more of the 2007
  PQRI measures. Eligible health care providers
  must select measures that are most applicable to
  their patient populations and report 80 of the
  time on these measures to potentially receive a
  bonus.

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PQRI Introduction

• The 2007 PQRI measures are posted on CMS website
  along with their specifications. The measure
  specifications may be updated and reposted prior
  to the July 1, 2007 start date to expand
  applicability of the measure. To view the
  measures please visit CMS website
  www.cms.hhs.gov/PQRI.

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PQRI Introduction

• Academy members have reviewed the 74 PQRI
  measures and identified measures that are
  applicable to some physiatrists. Within the PQRI
  program, the osteoporosis and stroke measures
  appear to be most appropriate for some
  physiatrists to utilize.

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PQRI Introduction

• The reporting period for the program is for the
  dates of service between July 1 and December 31,
  2007
• Reporting thresholds are set by statute. If
  there are no more than 3 measures that apply then
  each measure must be reported for at least 80 of
  the cases in which a measure was reportable
• The aforementioned information is copied from
  CMS website

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PQRI Introduction

• If 4 or more measures apply
• At least 3 measures must be reported for at least
  80 of the cases in which the measures was
  reportable
• If there are less than 3 measures that apply
• CMS is developing a validation protocol to ensure
  that other measures were not appropriate for
  reporting
• The aforementioned information is copied from
  CMS website

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PQRI Introduction

• Validation
• The statute requires CMS to use sampling or other
  means to validate whether quality measures
  applicable to the service have been reported
• The validation plan will be posted on CMS
  website prior to July 1, 2007 www.cms.hhs.gov/PQRI
  
• Appeals
• The statute excludes PQRI related determinations
  from formal administrative or judicial review
• The aforementioned information is copied from
  CMS website

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PQRI Introduction

• Bonus payment calculation is set by statute
• Participating eligible professionals who
  successfully report may earn a 1.5 bonus,
  subject to a cap
• The cap is meant to encourage more instances of
  measure reporting the more instances of
  reporting make the cap less likely to apply
• Bonus payments will be made to the holder of
  Taxpayer Identification Number (TIN) in a lump
  sum in mid-2008
• The aforementioned information is copied from
  CMS website

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PQRI Introduction

• Cap calculation
• 1. Individuals instances of reporting data
• X
• 2. 300
• X
• 3. National average per measure payment amount
• National average per measure payment amount
  National total charges associated with quality
  measures / National total instances of reporting
• The aforementioned information is copied from
  CMS website

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PQRI Overview

• Integration of PQRI quality data reporting into
  your care of delivery processes
• Select measures most appropriate for your
  practice
• Define roles of those involved in submission of
  data to ensure successful reporting
• Modify workflows and billing systems to increase
  efficiency of reporting
• The aforementioned information is copied from
  CMS website

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PQRI Overview

• Select measures that are most applicable for the
  services you provide to patients and consider
  your quality improvement goals for 2007. The
  Academy has aligned PQRI measures with various
  practice areas for physiatrists. Please review
  the specifications of the measures to determine
  if a particular measure is appropriate for your
  practice.

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PQRI Overview

• Orthopedic Rehabilitation
• 4) Screening for Future Fall Risk
• 24) Osteoporosis Communication with Physician
  Managing Ongoing Care
• 39) Screening or Therapy for Osteoporosis for
  Women Aged 65 Years and Older
• 41) Osteoporosis Pharmacological Therapy
• 42) Osteoporosis Counseling for Vitamin D,
  Calcium Intake, and Exercise
• The aforementioned information is copied from
  CMS website

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PQRI Overview

• Stroke/Neurological Rehabilitation
• 4) Screening for Future Fall Risk
• 31) Stroke and Stroke Rehabilitation Deep Vein
  Thrombosis (DVT) for Ischemic Stroke or
  Intracranial Hemorrhage
• 32) Stroke and Stroke Rehabilitation Discharge
  on Antiplatelet Therapy
• 33) Stroke and Stroke Rehabilitation
  Anticoagulant Therapy Prescribed for Atrial
  Fibrillation at Discharge
• 34) Stroke and Stroke Rehabilitation Tissue
  Plasma Activator (t-PA) Considered
• The aforementioned information is copied from
  CMS website

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PQRI Overview

• Stroke/Neurological Rehabilitation Cont.
• 35) Stroke and Stroke Rehabilitation Screening
  for Dysphagia
• 36) Stroke and Stroke Rehabilitation
  Consideration of Rehabilitation
• Spine Medicine Non-Interventional
• 4) Screening for Future Fall Risk
• 24) Osteoporosis Communication with the
  Physician Managing Ongoing Care Post Fracture
• The aforementioned information is copied from
  CMS website

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PQRI Overview

• Spine Medicine - Interventional
• 24) Osteoporosis Communication with the
  Physician Managing Ongoing Care
• Brain Injury Rehabilitation
• 4) Screening for Future Fall Risk
• 31) Stroke and Stroke Rehabilitation Deep Vein
  Thrombosis (DVT) for Ischemic Stroke or
  Intracranial Hemorrhage
• The aforementioned information is copied from
  CMS website

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PQRI Overview

• Spinal Cord Medicine
• 4) Screening for Future Fall Risk
• 24) Osteoporosis Communication with the
  Physician Managing Ongoing Care Post Fracture
• Occupational Rehabilitation
• 24) Osteoporosis Communication with the
  Physician Managing Ongoing Care Post Fracture
• The aforementioned information is copied from
  CMS website

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PQRI Overview

• Geriatrics
• 4) Screening for Future Fall Risk
• 24) Osteoporosis Communication with the
  Physician Managing Ongoing Care Post Facture
• 39) Screening or Therapy for Osteoporosis for
  Women Aged 65 Years and Older
• 41) Osteoporosis Pharmacological Therapy
• 42) Osteoporosis Counseling for Vitamin D,
  Calcium Intake, and Exercise
• 47) Advance Care Plan
• The aforementioned information is copied from
  CMS website

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PQRI Overview

• Disability/Impairment
• 4) Screening for Future Fall Risks
• Prosthetics Orthotics
• 4) Screening for Future Fall Risks
• Rheumatoid Arthritis
• 24) Osteoporosis Communication with the
  Physician Managing Ongoing Care Post Fracture
• The aforementioned information is copied from
  CMS website

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PQRI Overview

• Reporting Measure Data
• Determine the process by which you will report
  data once you have identified appropriate
  measures for the patient population that you
  serve. Assign responsibility and educate each
  team member to accurately and efficiently carry
  out the reporting process.
• The aforementioned information is copied from
  CMS website

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PQRI Overview

• Reporting Measure Data
• Discuss system capabilities with practice
  management software vendors and third-party
  billing vendors/clearing houses to determine what
  system changes may be required to capture quality
  data codes. CMS encourages participants to
  undertake this process prior to July 1, 2007.
• The aforementioned information is copied from
  CMS website

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PQRI Overview

• Reporting Measure Data
• CPT Category II codes may be reported on
  paper-based 1500 or electronic 873-P claims
• The CPT Category II code, which supplies the
  numerator, must be reported on the same claim
  form as the payment ICD-9 and CPT Category I
  codes, which supply the denominator
• The individual National Provider Identifier (NPI)
  of the professional must be properly used on the
  claim.
• Please click on the following link to learn
  additional information on obtaining an NPI
  number
• http//www.cms.hhs.gov/NationalProvIdentStand
• The aforementioned information is copied from
  CMS website

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PQRI Overview

• Reporting Measure Data
• Multiple CPT Category II codes can be reported on
  the same claim, as long as the corresponding
  denominator codes are on the claim
• The individual NPI of the participating
  professional must be properly used on the claim
• Line item charges should be 0.00. If the system
  does not allow 0.00, CMS recommends using a
  small amount like 0.01. Entire claims with a
  zero charge will be rejected by CMS
• The aforementioned information is copied from
  CMS website

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PQRI Overview

• The National Claims History (NCH) file must
  receive claims by February 29, 2008 to be
  included in the analysis
• Analysis will be performed by individual NPI
  under each TIN
• Ensure that your carrier/Medicare Administrative
  Contractor (MAC) has the accurate TIN for your
  claims
• The aforementioned information is copied from
  CMS website

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PQRI Overview

• Confidential Feedback Reports
• 2007 PQRI quality data will not be publicly
  reported
• Reports will be available at or near the time of
  the bonus payment in 2008
• Reports are expected to include reporting and
  performance rates by NPI for each TIN
• The aforementioned information is copied from
  CMS website

31
PQRI Program

• CMS intends to post additional guidelines for
  reporting data on its website prior to July 1,
  2007. www.cms.hhs.gov/PQRI

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Successful Reporting Scenario I
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Prospective Payment System

• When submitting data for the PQRI program,
  physiatrists MUST utilize ICD-9 codes that are
  included in BOTH the PQRI program and CMS
  Inpatient Rehabilitation Facility Prospective
  Payment System (IRF PPS). For example, stroke is
  part of the IRF PPS and the PQRI program. The
  following page provides ICD-9 codes for stroke
  that are included in both programs.

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Perspective Payment System

• The following ICD-9 codes are part of the IRF PPS
  and included in the PQRI stroke measures
• 431, 433.01,433.11,433.21,433.31,
• 433.81,433.91,434.01,434.11,434.91
• When submitting data on inpatient diagnoses for
  the PQRI program, physiatrists MUST utilize ICD-9
  codes included in the IRF PPS to be accounted for
  in both programs.

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Successful Reporting Scenario 2
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2008 PQRI Program

• Statutory requirements for 2008 measures
• Adopted or endorsed measures by a consensus
  organization, such as the AQA Alliance or the
  National Quality Forum
• Used a consensus-based process for development
• Include structural measures, such as the use of
  electronic health records or electronic
  prescribing technology
• The aforementioned information is copied from
  CMS website

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2008 PQRI Program

• Registry-Based Reporting
• CMS is working towards registry-based reporting
  for 2008
• Standardized specifications for centralization
  reporting could reduce the burden of reporting
  for participants and CMS
• The aforementioned information is copied from
  CMS website

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Additional Information

• CMS frequently posts new information on the PQRI
  program. Please click on the following website
  to learn the latest information.
• www.cms.hhs.gov/PQRI