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CAP Audio Conference on the

CMS 2009 Physician Quality Reporting Initiative

Jonathan Myles, MD, FCAP

College of American Pathologists

December 17, 2008

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PQRI Examples

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Case #1

A 65-year-old woman developed a 3cm breast mass and a subsequent needle biopsy specimen revealed infiltrating ductal carcinoma. After consultation with her surgeon, oncologist and radiation therapist, the patient elected to undergo a modified radical mastectomy with axillary lymph node dissection. The surgical pathology report from the resection includes pT, pN, and tumor grade. The pathologist has been participating in the PQRI for breast cancer specimens.

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Reporting on Case #1

• The PQRI code 3260F is entered into field 24D of the CMS-1500 hard copy form.

• If the pathologist was participating in PQRI and had not included pTpN in the surgical pathology report, the case would be coded with the (-8P) modifier.

• In both cases, the pathologist would be considered as meeting the PQRI requirement for reporting.

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Case #2A 75-year-old man came to his primary care physician for a routine annual visit. History revealed symptoms of fatigue. Physical examination was essentially unremarkable, but fecal occult blood testing was positive, and laboratory examination revealed a microcytic, hypochromic anemia. The patient was referred to a gastroenterologist. Outpatient sigmoidoscopic examination revealed a friable mass in the sigmoid colon. The mass was biopsied, and the specimen was sent to the hospital pathology laboratory, where it was examined and reported as showing infiltrating moderately differentiated adenocarcinoma. The patient was then referred to a surgeon, who performed a sigmoid resection and regional lymph node dissection at the same hospital. This specimen was sent to the same hospital pathology laboratory as the biopsy specimen. The surgical pathology report from the resection includes pT, pN, and tumor grade. The pathologist wishes to participate in the PQRI program.

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Reporting on Case #2

• The PQRI code 3260F is entered into field 24D of the CMS-1500 hard copy form for the resection specimen.

• The biopsy specimen is not covered by the measure, no CPT II code would be added for the biopsy specimen.

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Case #3

The patient with breast cancer  in Case #1 developed elevated liver enzymes one year later.  CT scan demonstrated a 2 cm mass in the liver.  A needle biopsy of the liver demonstrated metastastic adenocarcinoma. The pathologist wishes to participate in the PQRI program.

When coding the case, a secondary ICD9 code was entered which qualified the case for PQRI.

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Reporting on Case #3

• The correct CPT code for this case would be 88307 .

• The correct code to enter in field 24D on CMS form 1500 would be 3250F.

• The pathologist would be considered as having met the PQRI reporting requirement.

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Notes

Both the breast and the colorectal cancer reporting measures are in the same clinically related measures cluster (Pathology), so if a pathologist reports on breast cancer resection specimens and also colorectal cancer resection specimens in 2009, then he or she will have to submit quality-data codes on at least eighty percent of each of these two types of cancer resection specimens to earn his or her incentive payment.

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Notes

However, if a pathologist signs out only breast or only colon specimens, the physician is still eligible to participate in the PQRI program while only reporting on the one applicable measure.

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Questions