2008 Medicare PQRI


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Overview of the 2008 Medicare PQRI program

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2008 Medicare PQRI

  1. 1. Centers for Medicare & Medicaid Services 2008 Physician Quality Reporting Initiative (PQRI) December 19, 2007 1
  2. 2. Overview • PQRI Introduction: Information about PQRI • PQRI Tools: Implementing PQRI • PQRI Principles: Understanding the Measures • PQRI Coding: Examples of Measures • PQRI 2008: Additional Considerations • PQRI Readiness: Ensuring Success 2
  3. 3. 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. 3
  4. 4. PQRI Introduction: The Statute • Tax Relief and Healthcare Act (TRHCA) Section 101 Implementation – Eligible Professionals – Quality Measures – Form and Manner of Reporting – Determination of Successful Reporting – Bonus Payment – Validation – Appeals – Confidential Feedback Reports – 2008 Considerations – Outreach and Education 4
  5. 5. 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 5
  6. 6. PRQI Introduction: Building a Platform Visit Documented in Encounter Form Coding & Billing the Medical Record NCH Analysis Contractor National Claims Carrier/MAC History File Confidential Bonus Payment 6 Report Procurement Sensitive 6
  7. 7. PQRI Introduction: Successful Reporting • Determination of Successful Reporting – Reporting thresholds • If there are no more than 3 measures that apply, each measure must be reported for at least 80% of the cases in which a measure was reportable • If 4 or more measures apply, at least 3 measures must be reported for at least 80% of the cases in which the measure was reportable 7 Procurement Sensitive 7
  8. 8. PQRI Introduction: The Bonus • Bonus Payment – Participating eligible professionals who successfully report may earn a 1.5% bonus, subject to cap • 1.5% bonus calculation based on total allowed charges during the reporting period for professional services billed under the Physician Fee Schedule • Claims must reach the National Claims History (NCH) file by February 29, 2008 – Bonus payments will be made in a lump sum in mid-2008 – Bonus payments will be made to the holder of record of the Taxpayer Identification Number (TIN) – No beneficiary coinsurance 8 Procurement Sensitive 8
  9. 9. PQRI Introduction: The Cap Calculation • Bonus Payment – Cap may apply when relatively few instances of quality measures are reported – Cap calculation = 1. (Individual’s instances of reporting quality data) X 2. (300%) X 3. (National average per measure payment amount) National average per measure payment amount = (National charges associated with quality measures) / (National instances of reporting) 9 Procurement Sensitive 9
  10. 10. Physician Quality Reporting Initiative (PQRI) • Validation – TRHCA requires CMS to use sampling or other means to validate whether quality measures applicable to the services have been reported – Validation plan posted on website • Appeals – Determinations are excluded from formal administrative or judicial review – CMS will establish an informal inquiry process 10 Procurement Sensitive 10
  11. 11. PQRI Introduction: Feedback Reports • Confidential Feedback Reports – enable quality improvement at the practice level – include reporting and performance rates by NPI for each TIN. 11
  12. 12. PQRI 2008: Additional Reporting Options • Registry-based reporting – Use of a data system that collects PQRI measure data and quality data codes for electronic submission to a CMS- designated clinical data warehouse using a CMS-specified record layout based on PQRI measure specifications • Electronic health record (EHR)-based reporting – Specifications recently posted on the CMS website for the electronic reporting of 5 measures 12
  13. 13. Coding for Quality: PQRI Tools Implementing PQRI 13
  14. 14. 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. 14
  15. 15. 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 15
  16. 16. PQRI Tools: MLN 5640: Coding and Reporting Principles 16 Procurement Sensitive 16
  17. 17. PQRI Tools: The Measure List 17 Procurement Sensitive 17
  18. 18. PQRI Tools: Coding for Quality A Handbook for PQRI Participation 18 Procurement Sensitive 18
  19. 19. PQRI Tools: Check the Release Notes 19 Procurement Sensitive 19
  20. 20. PQRI Tools: Coding for Quality A 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 20
  21. 21. PQRI Tools: Coding for Quality A Handbook for PQRI Participation Examples of Clinical Conditions/Topics • Clinical Conditions • Clinical Topics – Asthma – Advance Care Planning – Cancer ( Breast, Colon, – Screening for Fall Risk CLL, etc) – Imaging – Chest Pain – Medication – COPD Reconciliation – CAD – Perioperative Care – Depression – Diabetes – GERD 21
  22. 22. PQRI Tools: Measure-specific Data Collection Worksheets • Measure Specific – Measure Description – Worksheet – Coding Specifications 22
  23. 23. Coding for Quality: PQRI Principles Understanding the Measures 23
  24. 24. PQRI 2008- Statutory Requirements Statutory Requirements for 2008 Measures • Adopted or endorsed by a consensus organization, such as the AQA Alliance or National Quality Forum (NQF) • Include measures that have been submitted by a physician specialty • Used a consensus-based process for development • Include structural measures, such as the use of electronic health records or electronic prescribing technology 24
  25. 25. Understanding the Measures: Commonalities • 119 unique measures associated with clinical conditions that are routinely represented on Medicare Fee-for-Service (FFS) claims – ICD-9-CM diagnosis codes – HCPCS codes 25
  26. 26. PQRI 2008: 119 Measures • Seven Categories of Measures – National Quality Forum-endorsed 2007 PQRI Quality Measures – AMA Physician Consortium for Performance Improvement developed measures – Measures for non-physician eligible professionals developed by Quality Insights of Pennsylvania – Structural measures related to EHRs and e-prescribing developed by Quality Insights – Measures from the AQA Alliance starter set – Other NQF-endorsed measures not included in 2007 PQRI – Measures under development by the American Podiatric Medical Association 26
  27. 27. 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 27
  28. 28. Understanding the Measures: Construct Clinical action required for reporting and performance ________________________________ Eligible cases for a measure (the eligible patient population associated with the numerator) 28
  29. 29. Understanding the Measures: Construct CPT II Code or Temporary G Code ________________________________ ICD-9-CM and CPT Category I Codes 29
  30. 30. Understanding the Measures: Quality Data Codes Quality-Data Codes translate clinical actions so they can be captured in the administrative claims process 30
  31. 31. 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) 31
  32. 32. 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. 32
  33. 33. 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 33
  34. 34. 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. 34
  35. 35. Understanding the Measures: Reporting Frequency • Each measure has a Reporting Frequency requirement for each eligible patient seen during the reporting period – Report one-time only – Report once for each procedure performed – Report for each acute episode 35
  36. 36. Coding for Quality: PQRI Coding Examples Of Measures 36
  37. 37. Coding for Quality: Example - Procedure Related Care Measure # 20 – Timing of Antibiotic Prophylaxis – Ordering Physician 37 Procurement Sensitive 37
  38. 38. 38 Procurement Sensitive 38
  39. 39. 39 Current Procedural Terminology © 2006 American Medical Procurement Sensitive Association. All Rights Reserved. 39
  40. 40. 40 Procurement Sensitive Current Procedural Terminology © 2006 American Medical Association. All 40 Rights Reserved.
  41. 41. Current Procedural Terminology © 2006 American Medical Association. All Rights Reserved. 41 Procurement Sensitive 41
  42. 42. Coding for Quality: PQRI 2008 Additional Considerations 42
  43. 43. PQRI 2008: Registries and EHR-based Data Submission • CMS plans to test two options for registry- based data submission • Self-nomination letters must be received by 6pm EST on January 4, 2008 43
  44. 44. PQRI 2008: Registries and EHR-based Data Submission • CMS plan to test the feasibility of offering eligible professionals the option of submitting clinical quality data extracted from EHRs directly to a data warehouse. • Self-nomination letters are due by 6pm EST on January 4, 2008 44
  45. 45. Coding for Quality: PQRI Readiness Ensuring Success 45
  46. 46. 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. 46 Current Procedural Terminology © 2006 American Medical Association. All Rights Reserved.
  47. 47. 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) inquiry management 47