While many have questioned the value of participating in pay for performance schemes in general or specifically Medicare’s Physician Quality Reporting Initiative, there are in fact several good reasons to get involved. However, none of these benefits are sufficient if the effort involved is too great. We have developed what we consider to be a very simple strategy that allows us to qualify for a bonus by meeting the 80% threshold of reporting on at least 3 appropriate measures. The key is to set up the program and then let it operate automatically. For 2008, the list of available criteria has been significantly expanded but since successful participation only requires a minimum of 3 measures and there is no bonus for reporting on more, there is little incentive to do more than the minimum. The only advantage of the expanded choices is to improve your chances of submitting sufficient volume to not be limited on your bonus. The bonus is based on a very complicated volume calculation to prevent payouts to physicians who only report a few patient claims during the year even though their reporting is 100% on those few claims. For most of us, once a moderate volume is reached, there is no more payment for greater participation. That may change in the future but for now, there is no incentive to go beyond the minimum.
Last year, the codes most appropriate to urology pertained to urinary incontinence and surgical care. These 5 codes are still available for reporting; the new codes have expanded your choices, not replaced existing codes. However, since it is still necessary to successfully report on at least 80% of any given measure, if you plan to participate for 2008, you must start immediately. Delaying even a few months may mean that it’s impossible to meet the 80% target even if you subsequently report 100% successfully.
Last year, 3 of the easiest codes for urology pertained to urinary incontinence (measures 48, 49 and 50). If you ignored the complex modifier system that was used to report failure to meet the measure (I assume every urologist asks about the presence of incontinence in every elderly woman he interviews as part of a complete GU exam, characterizes the type of incontinence and has some treatment plan in mind even if it is to defer active therapy), reporting can be automated such that every woman 65 years and older had a CPT II 1090F code attached to each visit claim (indicating that the presence or absence of incontinence was assessed). The PQRI code must be on the same claim as the E&M service when it is submitted; you cannot add codes for previous claims after they have been sent. The fact that there is no penalty for over-reporting makes submitting such codes easy and automated. Although the program only requires one submission per interval (the second 6 months of 2007 was the first interval; 2008 will be a full year), there is no penalty for additional reporting so rather than try to determine whether the code was already submitted, simply submit with every visit. Similarly, it is easy to add code 1091F (indicating the type of incontinence is characterized) for all women over 65 who have an ICD-9 code for incontinence on their claim as well as code 0509F to show that a plan of care exists. For each of these measures, we use a stamp on the outside of the chart once per interval to show that the code was submitted at least once but we’re not shy about reporting more than once.
For surgical patients, since we uniformly utilize DVT prophylaxis and appropriate antibiotic prophylaxis (this strategy assumes you always do the right thing and only addresses how you report that fact), the automatic addition of codes 4047F (use of antibiotics) and 4044F (use of DVT prevention) to each surgical code on each and every claim submitted to Medicare is easy. Even if the surgery performed was not on the list of those which CMS has decided must have prophylaxis, there is no penalty for over-reporting.
The thought behind this strategy is that it requires too much work to analyze each claim to decide if a PQRI code is necessary, which code to use, which modifier to use and track whether we have already reported. The time and effort to analyze each claim, each time is too costly to justify participation. However, if we automatically submit with each appropriate claim, there is virtually no work or time invested and the bonus is pure gravy.
Extending this program to 2008, Medicare has added 45 new measures, several of which relate to prostate cancer and a few additional refer to the use of electronic health records. As a specialty, we felt it was very important that urology took the lead in developing these criteria and indeed, they are written in a fashion that reflects our treatment philosophy. However, from a practical standpoint, if your office already reports on at least 3 other measures at least 80% of the time and your volume is reasonable, there will be no additional benefit from taking on an additional reporting burden. Moreover, while it should be easy to hit the 80% participation mark for these measures, it is unlikely that any of you has sufficient volume treating prostate cancer to impact whether you qualify for the full PQRI bonus you’re entitled to (if you lack the numbers to qualify otherwise and think reporting on these new measures will put you over the top, you must have a busy practice that focuses almost exclusively on prostate cancer). The 3 new measures most appropriate to urology are only reported in association with claims for treating prostate cancer by surgery, external radiation, brachytherapy or cryosurgery. In those cases, CPT II coding would indicate that you knew the PSA, grade and stage before treatment (measure 101—use code 3268F or a reason why you didn’t), that you did not perform an inappropriate bone scan for low risk disease (measure 102—use both codes 3270F and 3271F for low risk disease, another code to explain why you did do it or 3272F, 3273F or 3274F for other than low risk disease to exclude from the denominator calculations) and that you had fully informed the patient of all treatment options (including active surveillance) for clinically localized disease (measure 103—use code 4163F or a reason why you didn’t). Other prostate cancer measures (numbers 104 and 105) will primarily be used by radiation oncologists who treat with external radiation.
Based on the practical principle of KISS (keep it simple stupid), there is little incentive to report these new prostate cancer codes or those pertaining to structural measures like EMR if the volume you report on at least 3 other measures is sufficient and they will require much more mental effort than the measures reported last year. In short, the PQRI program is currently structured to dissuade most practitioners from adding any new measures to their reporting if you already have a successful system in place. Add to that the fact that the program offers too little potential financial bonus to justify any increase in overhead and I think you’ll agree with me that sticking with those measures you used last year is sufficient to claim a successful response to the Pay for Performance challenge. Nonetheless, I do recommend participating in this program since quality reporting is an issue of faith among payers and pay for performance programs will likely increase and become mandatory in the future. It’s best to gain experience now and prepare for more complicated programs early. You know that you do the right thing for your patients; P4P only requires that you tell others about it.
