Measuring Up

Time to adapt to new PQRI changes

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Edward R. Gaines III, JD, CCP, is vice president and chief compliance officer for Medical Management Professionals Inc. (Photo courtesy Medical Management Professionals Inc.)

Change is inevitable. In the case of the Physician Quality Reporting Initiative (PQRI) for 2010, a few new changes accompany the program.

For those who have reported in prior years since the inception of PQRI in 2007, these types of adjustments and alterations merely come with the territory. If you are new to PQRI reporting in 2010, there are a variety of materials on the Centers for Medicare and Medicaid Services (CMS) Web site with links to the 2010 measures and measure specifications, along with a PQRI implementation guide for those reporting for the first time.

But regardless of your status as a veteran or newcomer, it is always pertinent to review the basics of the PQRI reporting program.

By the Book

It should be noted that PQRI is only a reporting program at this point, and it is not based on outcomes or performance. Providers track PQRI through their national provider identifier, which means each individual provider can choose whether or not to participate. Physicians and mid-level providers such as CRNAs, PAs, and NPs can participate in the program.

There are a variety of reporting methods that include registry-based, claims-based, and electronic health record submission. The bonus for successful reporting in the 2010 period is 2 percent of the providers’ allowed Medicare charges, excluding clinical lab charges and drugs, which are not subject to a cap.

There are two reporting period options for the claims-based individual measure reporting. A provider can opt to report on three or more measures during the calendar year January 1, 2010 through December 31, 2010. Or a provider can adhere to new half-year option from July 1, 2010 through December 31, 2010. However, it should be noted that the bonus is only based on the allowed charges for the time period they have chosen to report on.

Measuring Up

The definition of “successful reporting” is based on meeting the 80 percent threshold for reporting on applicable claims for three or more measures. If a provider does not meet the threshold on at least three or more individual measures, a provider could potentially be ineligible for the bonus. If there are less than three measures applicable to the providers’ service offerings, and they report on less than three measures, their claim submissions can potentially be subject to a “measure validation” process to ensure there were not similar measures that could have been reported on. If they fail the measure validation process they could be ineligible for the bonus.

Besides the individual measure reporting, there are also measure groups that can be reported on, if applicable. Claims must have the PQRI code on the first claim submission to count towards successful reporting. Applicable claims with the PQRI codes must have a $0.00 (or $0.01 charge if applicable) on the PQRI codes on the claim form.

As in prior years, there are a number of new measures for 2010. Most notably, radiology measure 11 and other elements have been revised with the addition or deletion of CPT and ICD-9 codes. It is important to ensure that the measure specifications have not changed, or that the measure itself has not been retired when transitioning from reporting in 2009 to 2010. You must ensure that you are reporting appropriately based on the 2010 measures.

Applying a Modifier

If you feel overwhelmed, there are software tools that billing companies use to assist coders with a warning message when a reportable event is documented. For instance, this type of message is generated when an applicable CPT or CPT/ICD-9 code combination is entered into certain types of software.

Other types of software can provide additional layers of PQRI assistance to include an analysis of measures that are applicable to a practice based on past billing patterns, and down to editing for applicable PQRI code submissions. 

One of the goals of the PQRI program is to improve and enhance quality documentation. While the current PQRI program is only a reporting program that’s not based on performance, it may be moving toward such a structure in the future. Many people speculate that quality may become a driving factor in reimbursement methodology, and PQRI reporting is a forerunner to that end.
One example pertaining to the specifics of PQRI coding includes the -8P modifier, which denotes “action not performed, reason not otherwise specified.” The 8P modifier is applicable in many cases, but CMS warns against its indiscriminate use in the hope that many providers do not see it as a way to report but instead view it as a way to take a shortcut on documentation.

Many clinicians wonder if overusing the modifier could hurt a provider in any way, especially regarding the current year’s bonus. However, the appropriate use of the modifier will not harm or hinder a provider in obtaining a bonus.

But, CMS has published the following information in the 2010 PQRI implementation guide: “The 8P reporting modifier facilitates reporting an eligible case on a given measure when the clinical action does not apply to a specific encounter. EPs can use the 8P modifier to receive credit for satisfactory reporting but will not receive credit for performance. EPs should use the 8P reporting modifier judiciously for applicable measures they have selected to report. The 8P modifier may not be used indiscriminately in an attempt to meet satisfactory reporting criteria without regard toward meeting the practice’s quality improvement goals.”

With these words of wisdom, it’s wise to monitor the use and submission of the 8P within documentation.

The PQRI program is open to all eligible providers, and diligent participation in the program is highly advised. The first place to look for details and specifics is on the CMS Web site. In addition, you should be working with your consultant, as well as your billing and coding vendor, to assure this program is being met on your behalf.

– Edward R. Gaines III, JD, CCP, is vice president and chief compliance officer for Medical Management Professionals Inc. in Atlanta, Ga. Direct comments and questions to
editorial@rt-image.com.