PQRI Measures

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Medicare 2007 PQRI Quality Measures

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PQRI Measures

  1. 1. Centers for Medicare & Medicaid Services 2007 Physician Quality Reporting Initiative (PQRI) Coding for Quality: The Measures Module IV June 13, 2007 1
  2. 2. 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. 2
  3. 3. 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. 3
  4. 4. Overview • PQRI Introduction: Information about PQRI • PQRI Tools: Implementing PQRI • PQRI Principles: Understanding the Measures • PQRI Coding: Examples of Measures • PQRI Readiness: Ensuring Success 4
  5. 5. 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. 5
  6. 6. 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 6
  7. 7. PRQI Introduction: The Process Visit Documented in Encounter Form Coding & Billing the Medical Record NCH Analysis Contractor National Claims Carrier/MAC History File Confidential Bonus Payment 7 Report Procurement Sensitive 7
  8. 8. PQRI Introduction: Feedback Reports • Confidential Feedback Reports – enable quality improvement at the practice level – include reporting and performance rates by NPI for each TIN. 8
  9. 9. 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). 9
  10. 10. Coding for Quality: PQRI Tools Implementing PQRI 10
  11. 11. 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. 11
  12. 12. 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 12
  13. 13. PQRI Tools: The Measure List 13 Procurement Sensitive 13
  14. 14. PQRI Tools: MLN 5640: Coding and Reporting Principles 14 Procurement Sensitive 14
  15. 15. PQRI Tools: Coding for Quality A Handbook for PQRI Participation 15 Procurement Sensitive 15
  16. 16. 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 16
  17. 17. 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 17
  18. 18. PQRI Tools: Measure- specific Data Collection Worksheets • Measure Specific – Measure Description – Worksheet – Coding Specifications 18
  19. 19. 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. 19
  20. 20. Coding for Quality: PQRI Principles Understanding the Measures 20
  21. 21. 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 21
  22. 22. 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 22
  23. 23. Understanding the Measures: Construct Clinical action required for reporting and performance ________________________________ Eligible cases for a measure (the eligible patient population associated with the numerator) 23
  24. 24. Understanding the Measures: Construct CPT II Code or Temporary G Code ________________________________ ICD-9-CM and CPT Category I Codes 24
  25. 25. Understanding the Measures: Quality Data Codes Quality-Data Codes translate clinical actions so they can be captured in the administrative claims process 25
  26. 26. 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) 26
  27. 27. 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. 27
  28. 28. 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 28
  29. 29. 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. 29
  30. 30. 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 30
  31. 31. Coding for Quality: PQRI Coding Examples Of Measures 31
  32. 32. 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. 32
  33. 33. Coding for Quality: Example #1- Prevention Measure #4 – Screening for Future Fall Risk 33
  34. 34. 34 Procurement Sensitive 34
  35. 35. 35 Procurement Sensitive 35 Current Procedural Terminology © 2006 American Medical Association. All Rights Reserved.
  36. 36. 36 Procurement Sensitive Current Procedural Terminology © 2006 American Medical Association. All Rights Reserved. 36
  37. 37. 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) 37 Procurement Sensitive 37
  38. 38. 38 Procurement Sensitive 38
  39. 39. Tool: Worksheet 39 Procurement Sensitive Current Procedural Terminology © 2006 American Medical Association. All Rights 39 Reserved.
  40. 40. Current Procedural Terminology © 2006 American Medical Association. All Rights Reserved. 40 Procurement Sensitive 40
  41. 41. Coding for Quality: Example #3- Acute Episode of Care Management Measure #55 – Electrocardiogram (ECG) Performed for Syncope 41 Procurement Sensitive 41
  42. 42. 42 Procurement Sensitive 42
  43. 43. 43 Procurement Sensitive Current Procedural Terminology © 2006 American Medical Association. All Rights 43 Reserved.
  44. 44. Current Procedural Terminology © 2006 American Medical Association. All Rights Reserved. 44 Procurement Sensitive 44
  45. 45. Coding for Quality: Example #4- Procedural Related Care Measure # 20 – Timing of Antibiotic Prophylaxis – Ordering Physician 45 Procurement Sensitive 45
  46. 46. 46 Procurement Sensitive 46
  47. 47. 47 Current Procedural Terminology © 2006 American Medical Procurement Sensitive Association. All Rights Reserved. 47
  48. 48. 48 Procurement Sensitive Current Procedural Terminology © 2006 American Medical Association. All 48 Rights Reserved.
  49. 49. Current Procedural Terminology © 2006 American Medical Association. All Rights Reserved. 49 Procurement Sensitive 49
  50. 50. Coding for Quality: Example #5-Resource Utilization Measure #66 – Appropriate Testing for Children with Pharyngitis 50 Procurement Sensitive 50
  51. 51. 51 Procurement Sensitive 51
  52. 52. 52 Procurement Sensitive 52 Current Procedural Terminology © 2006 American Medical Association. All Rights Reserved.
  53. 53. Current Procedural Terminology © 2006 American Medical Association. All Rights Reserved. 53 Procurement Sensitive 53
  54. 54. Coding for Quality: Example #6- Care Coordination Measure # 47– Advance Care Plan 54 Procurement Sensitive 54
  55. 55. 55 Procurement Sensitive 55
  56. 56. 56 Procurement Sensitive Current Procedural Terminology © 2006 American Medical Association. All 56 Rights Reserved.
  57. 57. Current Procedural Terminology © 2006 American Medical Association. All Rights Reserved. 57 Procurement Sensitive 57
  58. 58. Coding for Quality: PQRI Readiness Ensuring Success 58
  59. 59. 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. 59 Current Procedural Terminology © 2006 American Medical Association. All Rights Reserved.
  60. 60. 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. 60 Current Procedural Terminology © 2006 American Medical Association. All Rights Reserved.
  61. 61. 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 61

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