We have addressed the importance of the Centers for Medicare & Medicaid Services’ Physician Quality Reporting Initiative several times in the past 2 years. We feel compelled to do so again, and PQRI will be the focus of this article.
Many physicians have expressed frustration with the program, as they have not received any bonus money for participation in 2007. Payments for 2008 efforts have not yet been made. Although payment is a nice incentive, it is not the main reason to participate.
That being said, the government is offering physicians more ways of getting paid to participate in a program that is surely going to be mandatory at some point. Recall that last year, funding for the PQRI program was extended as part of the Medicare Improvements for Patients and Providers Act of 2008 that blocked the conversion factor decrease for 2009. The PQRI program for 2009 provides two separate windows for payment for participation: The first window involves reporting measures for the entire year. The second allows participation in the second half of the year, starting July 1, 2009. Each window will pay a qualifying practices up to 2% of alMedicare allowable payments for the time they participate.
Advantages to participating
We recommend participating in the PQRI even if you do not receive bonus money. The advantage to participating is simple: You can participate without fear of making a mistake. There will be no audits. In addition, the measures are easy to identify, and almost every practice already does what Medicare is asking you to do.
The first measures for PQRI are designed to make sure that most participants already meet the standards. Why? The seemingly obvious answer is that if Medicare can get everyone used to the program, its expansion will be easier to implement. We have heard many practices comment that participation will only encourage Medicare to further the program. Make no mistake, the process of changing the way Medicare and other payers determine what services they will pay for is coming. The PQRI process is open; many other payers are approaching the same task in a manner that is more aggressive, and not so open.
As we have seen with payment issues in the past, the rules and regulations applied by Medicare significantly influence the behavior of all payers. PQRI and pay for performance will be no different.
Many physicians involved in the rule-making process and in their negotiations with Medicare believe that a list of participants is being kept, regardless of success in the bonus pool. The list of participants is thought to be more likely to receive some benefit from participation beyond the 2% bonus, and those not on the participant list likely will not be treated as favorably.
Urology offices can choose from a list of several measures for participation. A short list includes measures 20, 22, 23, 48, 49, 50, 102, 103, 104, 105, 114, 115, and 124. All measures can be found at http://www.auacodingtoday.com/
One example is measure 48. For this measure, you are required to report code 1090F at least once between now and the end of the year to indicate that you have assessed the presence or absence of urinary incontinence for female patients over age 65 when they are in your office for an E&M visit, regardless of the current diagnosis. You may add an –8P to the 1090F if you forgot to assess the patient.
The process for using this measure is fairly straightforward. If you identify your female patients over age 65, you can report the 1090F with any E&M code. You should already have a history form asking whether your patients are incontinent. However, you have time to develop the form if you have not already done so. Remember, Medicare will not audit your records for PQRI this year. You are only required to report the measure once in a 12-month period; however, reporting more frequently will not be held against you. Measures 49 and 50 also address incontinence and are similar. Measures 114, 115, and 124 are simple measures that can be routinely reported for specific patients with little additional effort. Measures 20, 22, and 23 can also be routinely reported with a standing order at the hospital.
We strongly encourage you to get on board, and we’ll leave you with two suggestions:
If you have electronic health records, ask your vendor if it has templates built to comply with PQRI. If not, and/or you are building your own templates, build the PQRI measures into the system. It will serve you well.
Check whether Medicare is receiving your PQRI codes by reviewing your explanations of benefits.
Ironically, Medicare will deny your PQRI codes although you will be reporting the codes with a charge of $0.00 or $0.01. If you are not seeing denied PQRI codes, they are not going to Medicare on the claim, and you will need to check with your practice management system vendor and clearinghouse to determine the problem.
Our concluding advice:
Participate in PQRI, and do it now.
Urologist Ray Painter, MD, is president of Physician Reimbursement Systems, Inc., in Denver and is also publisher of Urology Coding and Reimbursement Sourcebook.
Mark Painter is CEO of PRSUrology SC in Denver.
