pqri measures

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Centers for Medicare & Medicaid Services

2007 Physician Quality Reporting Initiative (PQRI)

Coding for Quality: The Measures

Module IVJune 13, 2007

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Disclaimers

This presentation was current at the time it was published or uploaded onto the web. Medicare policy changes frequently so links to the source documents have been provided within the document for your reference.

This presentation was prepared as a tool to assist providers and is not intended to grant rights or impose obligations. Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services. The Centers for Medicare & Medicaid Services (CMS) employees, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this guide. This publication is a general summary that explains certain aspects of the Medicare Program, but is not a legal document. The official Medicare Program provisions are contained in the relevant laws, regulations, and rulings.

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Disclaimers

The Medicare Learning Network (MLN) is the brand name for official CMS educational products and information for Medicare fee-for-service providers. For additional information visit the Medicare Learning Network’s web page at www.cms.hhs.gov/MLNGenInfo on the CMS website.

Current Procedural Terminology (CPT) is copyright 2006 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.

The International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) is published by the United States Government. A CD-ROM, which may be purchased through the Government Printing Office, is the only official Federal government version of the ICD-9-CM. ICD-9-CM is an official Health Insurance Portability and Accountability Act standard.

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Overview

• PQRI Introduction: Information about PQRI• PQRI Tools: Implementing PQRI• PQRI Principles: Understanding the

Measures• PQRI Coding: Examples of Measures• PQRI Readiness: Ensuring Success

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PQRI Introduction: Value-Based Purchasing

• Value-based purchasing is a key mechanism for transforming Medicare from a passive payer to an active purchaser.– Current Medicare Physician Fee Schedule is

based on quantity and resources consumed, NOT quality or value of services.

• Value = Quality / Cost– Incentives can encourage higher quality and

avoidance of unnecessary costs to enhance the value of care.

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PQRI Introduction: Focus on Quality

• PQRI reporting will focus attention on quality of care.– Foundation is evidence-based measures

developed by professionals– Measurement enables improvements in care– Reporting is the first step toward pay for

performance

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PRQI Introduction:The Process

Visit Documented in the Medical Record

Encounter Form Coding & Billing

Carrier/MAC

NCHAnalysis Contractor National Claims

History File

Bonus PaymentConfidential Report

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PQRI Introduction: Feedback Reports

• Confidential Feedback Reports– enable quality improvement at the

practice level– include reporting and performance

rates by NPI for each TIN.

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PQRI Introduction: Key Information

• Reporting period: Dates of Service between July 1, 2007 through December 31, 2007

• No need to register: just begin reporting• Must be an enrolled Medicare provider (but

need not have signed a Medicare participation agreement)

• Need to use individual National Provider Identifier (NPI).

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Coding for Quality:PQRI Tools

ImplementingPQRI

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PQRI Tools: Where to Begin

• Gather information and educational materials from the PQRI web page: www.cms.hhs.gov/pqri on the CMS website.

• Gather information from other sources, such as your professional association, specialty society or the American Medical Association.

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PQRI Tools: The PQRI Website

• www.cms.hhs.gov/pqri– Overview– CMS Sponsored Calls– Statute/Regulations/Program Instructions– Eligible Professionals– Measures/Codes– Reporting– Analysis and Payment– Educational Resources

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PQRI Tools:The Measure List

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PQRI Tools: MLN 5640: Coding and Reporting Principles

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PQRI Tools: Coding for QualityA Handbook for PQRI Participation

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PQRI Tools: Coding for QualityA Handbook for PQRI Participation

• Selecting measures and preparing to report• PQRI coding and reporting principles for the

claims based submission of quality data codes• Sample clinical scenarios for each measure, listed

by clinical condition/topic, describes successful reporting (and performance where applicable)

• PQRI Glossary• 2007 PQRI Code Master• Sample implementation flow chart

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PQRI Tools: Coding for QualityA Handbook for PQRI Participation

• Clinical Conditions– Asthma– Cancer ( Breast, Colon,

CLL, etc)– Chest Pain– COPD– CAD– Depression– Diabetes– GERD

• Clinical Topics– Advance Care Planning– Screening for Fall Risk– Imaging– Medication

Reconciliation– Perioperative Care

Examples of Clinical Conditions/Topics

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PQRI Tools: Measure- specific Data Collection Worksheets

• Measure Specific– Measure Description– Worksheet– Coding Specifications

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PQRI Tools:The Code Master

• Excel Spreadsheet– a sequential list of all ICD-9-CM (I9) – CPT ® (CPT4) codes (including CPT II Codes)– CPT II exclusion modifiers that are included in

the 2007 PQRI.

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Coding for Quality:PQRI Principles

Understanding the Measures

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Understanding the Measures:Commonalities

• 74 unique measures associated with clinical conditions that are routinely represented on Medicare Fee-for-Service (FFS) claims – ICD-9-CM diagnosis codes – HCPCS codes

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Understanding the Measures: Scope

• The measures address various aspects of quality care – Prevention– Chronic Care Management– Acute Episode of Care Management– Procedural Related Care– Resource Utilization– Care Coordination

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Understanding the Measures:Construct

Clinical action required for reporting and performance

________________________________Eligible cases for a measure (the eligible

patient population associated with the numerator)

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Understanding the Measures:Construct

CPT II Codeor

Temporary G Code ________________________________

ICD-9-CM and

CPT Category I Codes

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Understanding the Measures: Quality Data Codes

Quality-Data Codes translate clinical actions so they can be captured in the administrative claims process

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Understanding the Measures:Quality Data Codes

• Quality-Data Codes can relay that:– The measure requirement was met

or– The measure requirement was not met due to

documented allowable performance exclusions (i.e., using performance exclusion modifiers)

or– The measure requirement was not met and the

reason is not documented in the medical record (i.e., using the 8P reporting modifier)

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Understanding the Measures: The Performance Modifiers

• Performance Measure Exclusion Modifiers indicate that an action specified in the measure was not provided due to medical, patient or systems reason(s) documented in the medical record:

– 1P- Performance Measure Exclusion Modifier due to Medical Reasons– 2P- Performance Measure Exclusion Modifier used due to Patient

Reason– 3P- Performance Measure Exclusion Modifier used due to System

Reason• One or more exclusions may be applicable for a given

measure. Certain measures have no applicable exclusion modifiers. Refer to the measure specifications to determine the appropriate exclusion modifiers.

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Understanding the Measures: The Reporting Modifier

• Performance Measure Reporting Modifier facilitates reporting a case when the patient is eligible but the action described in a measure is not performed and the reason is not specified or documented– 8P- Performance Measure Reporting

Modifier- action not performed, reason not otherwise specified

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Understanding the Measures: Performance Time Frame

• Some measures have a Performance Timeframe related to the clinical action that may be distinct form the reporting frequency. – Perform within 12 months– Most Recent

• Clinical test result needs to be obtained, reviewed, reported one time. It need not have been performed during the reporting period.

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Understanding the Measures: Reporting Frequency

• Each measure has a Reporting Frequencyrequirement for each eligible patient seen during the reporting period – Report one-time only– Report once for each procedure performed– Report for each acute episode

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Coding for Quality:PQRI Coding

ExamplesOf

Measures

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Coding for Quality

• NOTE: The following are examples of draft worksheets that will be made available soon to facilitate PQRI data capture and reporting.

• In some cases, the material upon which they are based has changed. Final data worksheets and supporting documents will be available on the CMS PQRI website in advance of July 1, 2007.

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Coding for Quality:Example #1- Prevention

Measure #4 – Screening for Future Fall Risk

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35Current Procedural Terminology © 2006 American Medical Association. All Rights Reserved.

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36Current Procedural Terminology © 2006 American Medical Association. All Rights Reserved.

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Coding for Quality:Example #2-Chronic Care Management

Measure #5 – Angiotensin Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB)

Therapy for Left Ventricular Systolic Dysfunction (LVSD)

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Tool: Worksheet

Current Procedural Terminology © 2006 American Medical Association. All Rights Reserved.

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Current Procedural Terminology © 2006 American Medical Association. All Rights Reserved.

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Coding for Quality:Example #3- Acute Episode of Care Management

Measure #55 –Electrocardiogram (ECG) Performed for Syncope

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43Current Procedural Terminology © 2006 American Medical Association. All Rights Reserved.

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Current Procedural Terminology © 2006 American Medical Association. All Rights Reserved.

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Coding for Quality:Example #4- Procedural Related Care

Measure # 20 – Timing of Antibiotic Prophylaxis –

Ordering Physician

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47Current Procedural Terminology © 2006 American Medical Association. All Rights Reserved.

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48Current Procedural Terminology © 2006 American Medical Association. All Rights Reserved.

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Current Procedural Terminology © 2006 American Medical Association. All Rights Reserved.

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Coding for Quality:Example #5-Resource Utilization

Measure #66 – Appropriate Testing for Children with

Pharyngitis

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52Current Procedural Terminology © 2006 American Medical Association. All Rights Reserved.

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Current Procedural Terminology © 2006 American Medical Association. All Rights Reserved.

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Coding for Quality:Example #6- Care Coordination

Measure # 47– Advance Care Plan

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56Current Procedural Terminology © 2006 American Medical Association. All Rights Reserved.

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Current Procedural Terminology © 2006 American Medical Association. All Rights Reserved.

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Coding for Quality:PQRI Readiness

Ensuring Success

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PQRI Reporting: Ensuring Success

• Eligible professionals interested in testing their billing system and practice readiness prior to July 1 will have an opportunity to do so.

• CMS has designated code G8300 as a test code for PQRI reporting for dates of service prior to July 1, 2007. Note that G8300 will become 'Not Valid for Medicare Purposes’effective for dates of service on and after July 1, 2007. Providers should not submit this code on claims for dates of service on and after July 1.

• Simply add the G8300 as a line item on any claims for services prior to July 1, 2007.

• Enter “$0.00” or “$0.01” as the line item charge for the test code. This will test the ability of the billing software or clearance house to accept either.

Current Procedural Terminology © 2006 American Medical Association. All Rights Reserved.

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PQRI Reporting: Ensuring Success

• Start reporting early to increase the probability of achieving the 80 percent rate of reporting during the reporting period.

• Report on as many measures as possible to increase the likelihood of achieving successful reporting.

• Report on as many eligible patients as you can to decrease the probability of being subject to the bonus cap.

• Ensure that quality codes are reported on the same claim as the diagnosis or CPT-I codes.

Current Procedural Terminology © 2006 American Medical Association. All Rights Reserved.

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PQRI Reporting:Ensuring Success

• Educational Resources– CMS PQRI website contains all publicly available

information at: www.cms.hhs.gov/PQRI• Frequently Asked Questions• PQRI Fact Sheet• Medicare Carrier/Medicare Administrative Contractor (MAC)

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