CMS’ 2007 Physician Quality Reporting Initiative (PQRI)

Last month, the Centers for Medicare and Medicaid Services (CMS) started their pay-for-reporting program (P4R) as mandated under the Tax Relief and Health Care Act of 2006.

Eligible Participants: Private practice and hospital-based physicians, including physicians that are hospital employees, can participate in the 2007 Physician Quality Reporting Initiative (PQRI). Nurse practitioners, clinical nurse specialists, physician assistants, clinical social workers, clinical psychologists, registered dietitians, nutritional professionals, physical therapists, and occupational therapists are also eligible to participate.

How to Participate: Participants do not have to register to participate in the 2007 PQRI. Providers will report the services using G codes and CPT category II codes that will match each quality measure under the PQRI. These codes can be reported on paper-based CMS 1500 claims or electronic 837-P claims. You will need to modify your billing form to add the new G codes applicable to your specialty. The choice of coding sets is up to you. If a patient has a contraindication to a particular measure, there is a “Not Applicable” response that can be coded. Your specialty organization has probably prepared tips for participation. You do not need an electronic medical record to participate.

The Need for Your NPI: The analysis of whether you have successfully reported your quality measures will be tied to the physician’s individual NPI, which must be listed along with the HCPCS codes for services, procedures, and quality data on the claim.

The Potential Return: There will be a 1.5 percent bonus calculated as a percentage of your total allowed Medicare physician charges between July 1 and December 31, 2007. This bonus will be paid for “successful” reporting of 74 quality measures payable to the holder of the taxpayer ID on the claim. The PQRI will include claims submitted by February 2008.

The Definition of a “Successful” Report: When three or fewer quality measures of the 74 are applicable to the services provided for a particular patient visit, each of the three measures must be reported in 80 percent of targeted patients. When four or more measures are applicable to the services rendered at a targeted patient visit, at least three of the measures must be reported 80 percent the targeted patients. Some of the measures apply only to select specialties. It is expected that the determination of “successful” reporting will be validated by a method of sampling that has yet to be fully elucidated. The confusion surrounding the definition of a “successful report” and the lack of clear methodology for both sampling and data validation leaves many of us concerned.

The 74 Measures in 30 Clinical Situations:

1. For Type 1 or Type 2 Diabetes Mellitus: HbA1C, LDL, blood pressure control, and for those patients with retinopathy, a dilated macular or fundus exam and documented communication by the examiner to the physician managing the day-to-day care.
2. For Patients > 65 Years Old: Fall risk prevention counseling will be measured.
3. For Patients With Heart Failure: ACE inhibitor or ARB and beta blocker therapy for left ventricular systolic dysfunction.
4. For Patients With Coronary Artery Disease: Oral antiplatelet therapy and beta blocker for patients with prior myocardial infarction and aspirin and beta blocker within 24 hours of an ER visit for MI and percentage of patients with CABG using internal mammary artery and preoperative beta blocker in patients with CABG and proper discontinuation of prophylactic antibiotics within 48 hours of a cardiac procedure.
5. For Patients With Syncope (Over Age 60 Years) or Nontraumatic Chest Pain (Over Age 40 Years): Documentation of an EKG.
6. Medication Reconciliation in Patients Over Age 65 Years: In the physician office within 60 days of discharge.
7. Advanced Directives: In patients over age 65 years.
8. Urinary Incontinence: Women aged 65 years or older require assessment for the presence or absence of urinary incontinence and those with incontinence must have their incontinence characterized and there needs to be a documented plan of care in females with incontinence.
9. Patients With GERD: Assessment for “alarm symptoms” of involuntary weight loss, dysphagia, and GI bleeding and documentation of upper GI or endoscopy in patients with one or more alarm symptoms and if endoscopy, biopsy for Barrett’s esophagus.
10. Patients With Pneumonia: Documentation and review of vital signs, mental status, and oxygen saturation and appropriate use of antibiotics.
11. Patients With Chronic Obstructive Pulmonary Disease: Documentation of spirometry and for those patients with FEV1/FVC < 70 percent, the prescription of an inhaler.
12. Patients Age 5 to 40 Years With Asthma: Use of inhaled corticosteroids or other acceptable alternative and every 12-month visit to assess for daytime or nocturnal symptoms.
13. Children Ages 3 Months to 18 Years With Viral URTI: Who were not given antibiotics.
14. Children Ages 2 to 18 Years of Age With Pharyngitis: Who received a strep test.
15. For Patients With New Episode of Major Depression: Antidepressant therapy for the acute phase.
16. Stroke, TIA, or Intracranial Hemorrhage Patients: Report of CAT or MRI and carotid imaging of the brain within 24 hours of arrival to the hospital and proper DVT prophylaxis for stroke or ICH by end of hospital day two and for patients with ischemic stroke, t-PA within 3 hours of arrival and for stroke or TIA, discharge on antiplatelet therapy and anticoagulants for patients with permanent or persistent atrial fibrillation and for patients with stroke or ICH, dysphagia screen before taking foods and consideration of rehabilitation services in patients with stroke or ICH.
17. Patients With Primary Open-angle Glaucoma: Optic nerve head evaluation in the prior 12 months.
18. Patients With Age-related Macular Degeneration (Over Age 50): Dilated macular exam within the prior 12 months.
19. Patients With Cataracts: Will need to have a visual function exam in the prior 12 months, and those with cataract surgery will require a presurgical fundus exam, axial length, corneal power measurement, and an intraocular lens power calculation in the six months prior to surgery.
20. All Surgical Patients Where Prophylactic Antibiotics Are Indicated: Proper timing of order and administration one to two hours prior to start of procedure and use of a first- or second-generation cephalosporin and proper discontinuation within 24 hours of surgical end time and proper venous thromboembolism prophylaxis.
21. Patients With Osteoporosis: Proper communication with the PCP of care of patients status post fracture and Dexa in women over age 60 if under therapy for osteoporosis or if history of fracture over age 50 and proper pharmacologic therapy and counseling.
22. All Cancer Patients: Clear and written documentation of treatment plan prior to initiation of chemotherapy.
23. Patients With Melanoma: Documentation of query regarding new or changing moles and complete exam of skin and counseling regarding self exam.
24. Patients With Myelodysplastic Syndrome and Acute Leukemia: Documentation of cytogenetic testing and documentation of iron stores prior to initiating erythropoietin therapy.
25. Patients With Multiple Myeloma Not in Remission: Documentation of IV biophosphonate therapy in the prior 12 months.
26. Chronic Lymphocytic Leukemia: Documentation of baseline flow cytometry.
27. Patients With Stage IC to III, ER/PR Positive Breast Cancer: Documentation of their receiving Tamoxifen or Aromatase Inhibitor.
28. Patients With Invasive Breast Cancer S/P Breast Conserving Surgery: Documentation of recommendation for radiation therapy.
29. Patients With Stage III Colon Cancer: Documentation of chemotherapy.
30. Patients With End-stage Renal Disease: Proper documentation of renal function and Hct of 33 or greater.

The Complexities: The bonus will apply to allowed charges for all covered professional services, not just those charges associated with reported quality measures. The term “allowed charges” refers to total charges, including the beneficiary deductible and co-payment, not just the 80 percent paid by Medicare or the portion covered by Medicare where Medicare is the secondary payer. Payment applies to those covered services under the physician fee schedule only, which includes technical components of diagnostic services. Other Part B services and items that may be billed by eligible professionals but are not paid under the physician fee schedule, such as clinical laboratory services and pharmaceuticals billed by physicians, do not apply to the bonus.

Appeals and Access to Data: The statute specifically states that there shall be no administrative or judicial review of the determination of: 1) quality measures applicable to services furnished by eligible professionals; 2) satisfactory reporting; 3) the payment limitation or cap; or 4) the bonus incentive payment. However, CMS will establish a process for eligible professionals to inquire about these matters. CMS will provide confidential feedback reports to participating eligible professionals at or near the time that the lump-sum bonus payments are made in mid-2008. There will be no interim feedback during 2007. Quality data reported under the 2007 PQRI will not be publicly reported.

Warning: There is no cap to the dollars that are paid out nationally for 2007, and the bonus will be a one-time payment that will arrive in the summer of 2008. The major flaw that I see with the program is that the dollar amount is based upon each physician’s total charges, and the PQRI 1.5 percent bonus payment is subject to a cap of $1.35 billion for 2008. Physicians who do not routinely rack up large annual charges may not see sizeable checks for their efforts, especially if the cap is reached. Cardiologists, radiologists, high-cost surgeons, and ophthalmologists will do well, but for family practitioners and internists, the dollar amount may not be worth the headache. Furthermore, no one knows yet how intrusive the audit process will be. I will also be surprised if CMS can administer the program as advertised, and even more surprised if the payment is accurate or arrives on time.

To Stay Updated: Detailed program instructions, educational materials, and supportive tools will be posted as they become available on the CMS PQRI website at: http://cms.hhs.gov/PQRI. Future measures to be considered for eligibility will be posted for public comment by August 15, 2007.