Medicare is preparing to change its approach to health care payments. For years, the Centers for Medicare & Medicaid Services has considered itself a passive payer for health care services, which allowed it to essentially establish and control how much it will pay for various services. Over the years, it has placed restrictions on the number of times a service will be paid and on payment for services for treatment for particular medical problems. Medicare payment policies have rarely addressed which service is the most effective for treatment of a given disease (one notable exception being the least costly alternative policies for LHRH drugs).
In changing from a passive payer to an active purchaser of health care, Medicare will need more data related to quality of care. The Physician Quality Reporting Initiative (PQRI) is a program established at the end of last year to provide incentive funding for physicians to begin submitting data that will be used to make Medicare a smarter purchaser of health care. The PQRI program will run from July 1, 2007, through Dec. 31, 2007. Physicians can participate if they submit bills to Medicare and have a national provider number; there is no signup or enrollment process.
The incentive for participating in the program is a 1.5% bonus for each physician meeting certain participation levels. The bonus will be calculated on the aggregate approved allowed amount for all claims submitted by each qualified provider during the data collection period. The approved allowed amount is the amount paid by Medicare and the recipient, including deductibles and co-payments for services provided to Medicare beneficiaries. The bonus is subject to a cap established by a formula we have yet to figure out and will be paid in a lump sum in 2008. To be eligible for the bonus, you must submit the required coding on at least 80% of three measures selected by the office that are applicable to your patients.
Currently, CMS has provided reporting specifications for 74 measures. We have identified 12 measures that may apply to urologists. However, each physician will need to determine the three most appropriate measures to use. Space does not allow us to include all 12 measures here. For all measures and related information, review the information posted on the CMS web site at http://www.cms.hhs.gov/PQRI/. The 12 measures identified for urology include measures 20 to 23, 30, 37, 41, 42, 46, 48, 49, and 50, and address issues related to perioperative care, osteoporosis and incontinence.
Each measure identifies circumstances that require additional reporting by ICD-9 and/or CPT codes (denominator). The required CPT category II codes or G codes that are to be reported on claims for these patients with a charge of $0.00 (or $0.01 if your system will not process $0.00 charge claims) are listed in the measure (numerator). In addition, there are four modifiers that can be appended to the category II codes or G codes describing circumstances that caused the patient to not receive the measure. Each measure description will also identify the allowed modifier for the measure.
All of this may sound a bit foreign, so we will break down measure 23, reporting on venous thromboembolism (VTE) prophylaxis.
First, see the list of CPT codes in the box (“Example CPT codes”) below for all patients receiving a service from this list.
Report CPT category II Code 4044F: Documentation that an order was given for VTE prophylaxis to be given within 24 hours prior to incision time or 24 hours after surgery end time with a charge of $0.00.
If the VTE was not ordered, you will append modifier 1P (not ordered/given for medical reasons documented in the chart) or 8P (not ordered/given for unspecified reason) to code 4044F to indicate the circumstance documented as the reason the VTE was not ordered or given.
Implementation strategies
The instructions for this are relatively easy to understand. Implementation will take some planning and execution by each office. We continue to evaluate multiple strategies to effectively include PQRI in your office.
Currently, we recommend that you develop a charge sheet add-on including the codes for the three selected measures so that the physician can communicate the measure codes for each patient qualifying. This method will require those measures provided in a hospital setting to be communicated via charge sheet, as well as in-office procedures and services. There will be suggested forms posted on http://www.aua.codingtoday.com/ this month, which will include all measures listed under the codes and full text for the measure. We are interested in other suggestions you may have to handle this additional reporting requirement.
AUA, Physician Reimbursement Systems, and others are encouraging your participation in PQRI. The 1.5% bonus will provide some cost offset for the time and materials required for participation.
In summary, we would like to put pay for performance and PQRI in perspective as we look to the future. Major employers, private payers, unions, and other federal programs have implemented or are planning to join Medicare in implementing pay for performance programs soon. In other words, PQRI is the tip of a large iceberg directly in the path of your bottom line. You can participate, learn, and live with the program, or prepare to board your life raft.
Urologists need to act now to collect and organize our practice data in order to prove the quality and cost efficiency of our practices. AUA is already developing guidelines and measures. We need to do our part by providing quality data to validate what we know.
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 PRS Urology SC in Denver.
Disclaimer:
The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written. However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.
