- Email: [email protected]
The Medicare Physician Quality Reporting Initiative
CHEST
Topics in Practice Management
The Medicare Physician Quality Reporting Initiative What Do Chest Physicians Need to Know? Mark L. Metersky, MD, FCCP
Health-care consumers, payers, and regulatory agencies have become increasingly concerned about the rising cost and perceived deficiencies in the quality of health care in the United States. Pay-for-performance initiatives, otherwise known as value-based purchasing, are gathering political and public support as a method to address these problems. The Centers for Medicare and Medicaid Services is moving rapidly toward a system in which reimbursement is linked to quality of care. Serving as a first step, the Medicare Physician Quality Reporting Initiative (PQRI) is a program that rewards providers for reporting their performance on certain quality measures. Participating providers receive a bonus equal to 2% of their entire Medicare reimbursement for the calendar year if they successfully report on at least three measures for 80% of relevant patients seen during that year. The performance data are submitted via specifically designated Current Procedural Terminology II codes that are added to the usual codes submitted on the billing claim. Physicians should strongly consider participating in PQRI because it is likely to form the framework for future pay for performance, in which the dollars at stake may be much higher. (CHEST 2009; 136:1644 –1649) Abbreviations: ACCP ⫽ American College of Chest Physicians; CMS ⫽ Centers for Medicare and Medicaid Services; CPT ⫽ Current Procedural Terminology; EHR ⫽ electronic health record; ICD-9-CM ⫽ International Classification of Diseases, ninth revision, clinical modification; NPI ⫽ national provider identifier; PQRI ⫽ Physician Quality Reporting Initiative
of less than optimum quality and T hethecombination spiraling cost of medical care in the United States has led the Centers for Medicare and Medicaid Services (CMS), the Joint Commission for the Accreditation of Healthcare Organizations, managed care organizations, and large employers to search for new methods of reimbursing health-care providers, in hopes of encouraging the provision of higher quality and more cost-effective care. CMS has clearly Manuscript received January 25, 2009; revision accepted March 2, 2009. Affiliations: From the Division of Pulmonary and Critical Care Medicine, University of Connecticut School of Medicine, Farmington, CT. Correspondence to: Mark L. Metersky, MD, FCCP, Division of Pulmonary and Critical Care Medicine, University of Connecticut Health Center, 263 Farmington Ave, Farmington, CT 06030-1321; e-mail: [email protected] © 2009 American College of Chest Physicians. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/site/ misc/reprints.xhtml). DOI: 10.1378/chest.09-0193 1644
demonstrated its intention to change the reimbursement paradigm from the fee-for-service system that is currently used to a pay-for-performance, or valuebased purchasing, scheme.1,2 Implementing this type of reimbursement scheme will require that providers be regularly assessed with regard to their For editorial comment see page 1452 quality of care by the use of validated performance measures.3 As a first step, CMS implemented the Physician Quality Reporting Initiative (PQRI) in 2007.4,5 In this optional program, providers receive financial compensation in return for reporting data regarding their performance on certain quality measures. Although it was previously unclear how long this program was going to last, at the end of 2008 Congress passed legislation making it “permanent.”6 Approximately 16% of eligible providers (109,000) participated in the PQRI during the 2007 measureTopics in Practice Management
ment period, of whom 52% received a financial incentive. In the future, it is likely that the PQRI will become mandatory for physicians caring for Medicare patients, and it is expected that the program will move toward rewarding providers for the quality of care being provided, not just for reporting the quality of care.3 Financial penalties for reporting poor quality of care are also likely to ensue. The purpose of this article is to review the CMS PQRI program so that physicians can participate effectively as it is currently structured and can be prepared for the future, when PQRI and programs like it will assume greater importance.
Structure of the PQRI Health-care providers, including but not limited to physicians, nurse practitioners, and physicians’ assistants, who see fee-for-service Medicare patients may participate in PQRI. Those participating must choose a minimum of three relevant quality measures to report on to be eligible for a financial bonus. Providers who successfully report on 80% of appropriate patients for each of three measures will receive the bonus. Thus, physicians receive bonus payments for reporting performance or nonperformance of the recommended process of care; incentives are not currently based on how often physicians provided the recommended care. There is no public reporting of the results; however, CMS has indicated that it is planning to publicly report whether or not individual physicians participated in PQRI during 2009. The bonus payment for the 2009 reporting period is 2.0% of the total Medicare reimbursement received during the January 1, 2009, to December 31, 2009, calendar year. This will not change for 2010. A physician’s performance is calculated based on his or her individual performance, linked to their national provider identifier (NPI), even if they belong to a group practice or are an employee of another entity, such as a hospital. However, the bonus is payable to the taxpayer identification number under which the physician is billing CMS. For the first time in 2010, a group practice can choose for the performance of the group as a whole to be the unit of measurement, as opposed to the performance of the individual providers. This means that if the group reaches the performance target of 80%, the group receives the 2% bonus, even if some providers are under the target. Although the PQRI program has not been without glitches, the basic design of the program is admirable in its simplicity. Providers do not have to register to participate in the program, nor do they have to prospectively inform CMS of which measures they www.chestjournal.org
wish to report. Participating physicians select three or more of the measures relevant to their practice. Physicians who choose to submit data on more than three measures will receive a bonus if they reach the 80% reporting threshold for three measures. See Table 1 for a list of the measures most relevant to pulmonary and critical care physicians. The relevant diagnoses for each measure are defined by a list of International Classification of Diseases, ninth revision, clinical modification (ICD-9-CM) codes that identify the patient as having the relevant clinical condition. For many of the diagnoses, including pneumonia, COPD and asthma, there are several ICD-9-CM codes that are relevant. When a claim is submitted for a patient with an appropriate diagnosis, one or more category II Current Procedural Terminology (CPT) codes are submitted in addition to the usual CPT codes that providers use to identify the specific evaluation and management service or procedure that is being billed. Category II CPT codes were developed to represent processes of care related to specific performance measures, as well as to represent any exceptions, reasons that a service was not provided. Unlike regular CPT codes, they are not associated with any charge. See Figure 1A and B for an example of all the category II CPT codes related to the asthma and COPD measures, respectively. Once a category II CPT code associated with a specific measure is reported, CMS will assume that all patients with the relevant diagnosis seen by that provider are eligible for reporting. For example, if a provider reports: CPT II 3023F (spirometry results documented and reviewed) for a COPD patient (ICD-9-CM code 496), CMS will know that that physician is reporting on that measure and will include all fee-for-service Medicare COPD patients seen in an outpatient setting by that provider during the measurement period. These patients are placed in the reporting physicians’ denominator when a claim for a relevant service (identified by the CPT code) is submitted with any of the ICD-9-CM codes that identify the patient as having COPD. The provider will then have to report an appropriate CPT II code for ⱖ 80% of COPD patients for whom they submit a claim to CMS to reach the target for that measure. Note that this means the provider is not responsible for reporting on a patient if the patient is not seen during that billing year. Also, most measures are linked to specific categories of service. For example, the asthma measures of controller use and assessment of symptoms are linked to outpatient evaluation and management CPT codes only. A provider will not get credit for reporting one of these codes linked to a CHEST / 136 / 6 / DECEMBER, 2009
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Table 1—Relevancy Measures Included in the 2009 PQRI and Accompanying CPT Category II Codes Indicating Performance of the Recommended Service COPD Measure 51: COPD: spirometry evaluation Percentage of patients ⱖ 18 yr of age with a diagnosis of COPD who had spirometry evaluation results documented CPT II 3023F: spirometry results documented and reviewed Measure 52: COPD: bronchodilator therapy Percentage of patients ⱖ 18 yr of age with a diagnosis of COPD and who have an FEV1/FVC ⬍ 70% and have symptoms who were prescribed an inhaled bronchodilator CPT II 4025F: inhaled bronchodilator prescribed And CPT II 3025F: spirometry test results demonstrate FEV1/FVC ratio ⬍ 70% with COPD symptoms (eg, dyspnea, cough/sputum, wheezing) Asthma Measure 53: asthma: pharmacologic therapy Percentage of patients 5 to 40 yr of age with a diagnosis of mild, moderate, or severe persistent asthma who were prescribed either the preferred long-term control medication (inhaled corticosteroid) or an acceptable alternative treatment CPTII 4015F: persistent asthma, preferred long-term control medication, or acceptable alternative treatment prescribed And CPTII 1038F: Persistent asthma (mild, moderate, or severe) Measure 64: asthma assessment Percentage of patients 5 to 40 yr of age with a diagnosis of asthma who were evaluated during at least one office visit within 12 mo for the frequency (numeric) of daytime and nocturnal asthma symptoms CPT II 1005F: asthma symptoms evaluated (includes physician documentation of numeric frequency of symptoms or patient completion of an asthma assessment tool/survey/questionnaire) Pneumonia Measure 56: vital signs for community-acquired bacterial pneumonia Percentage of patients ⱖ 18 yr of age with a diagnosis of community-acquired bacterial pneumonia with vital signs documented and reviewed CPT II 2010F: vital signs (temperature, pulse, respiratory rate, and blood pressure) documented and reviewed Measure 57: assessment of oxygen saturation for community-acquired bacterial pneumonia* Percentage of patients ⱖ 18 yr of age with a diagnosis of community-acquired bacterial pneumonia with oxygen saturation documented and reviewed CPT II 3028F: oxygen saturation results documented and reviewed Measure 58: assessment of mental status for community-acquired bacterial pneumonia Percentage of patients ⱖ 18 yr of age with a diagnosis of community-acquired bacterial pneumonia with mental status assessed CPT II 2014F: mental status assessed Measure 59: empiric antibiotic for community-acquired bacterial pneumonia Percentage of patients ⱖ 18 yr of age with a diagnosis of community-acquired bacterial pneumonia with an appropriate empiric antibiotic prescribed CPT II 4045F: appropriate empiric antibiotic prescribed Measure 76: prevention of catheter-related bloodstream infections: CVC insertion protocol Percentage of patients, regardless of age, who undergo CVC insertion for whom CVC was inserted with all elements of maximal sterile barrier technique (cap and mask and sterile gown and sterile gloves and a large sterile sheet and hand hygiene and 2% chlorhexidine for cutaneous antisepsis or acceptable alternative antiseptics per current guideline) followed CPT II 6030F: all elements of maximum sterile barrier technique followed Other codes for documenting exceptions and nonperformance exist for each measure. Adapted from Baumann and Dellert.3 CVC ⫽ central venous catheter. *Although oxygen assessment for patients with community-acquired pneumonia remains a measure for the 2009 PQRI program, it is no longer one of the CMS core measures for patients admitted to the hospital with pneumonia.
claim for an influenza vaccination, for example. Similarly, the measures related to inpatient hospital care are not linked to CPT codes that identify outpatient services. CMS is aware that for many measures a performance target of 100% is not achievable and that for some would not even be desirable because it would lead to inappropriate overuse. Thus, there are category CPT II codes that allow documentation of exceptions, that is, reasons that a measured element of care was not provided. These include medical 1646
factors, patient-related factors, and systems factors. For example, a medical reason for not providing an influenza vaccine would be egg allergy, a patientrelated factor would be patient refusal, and a systems factor would be lack of available vaccine. Note that these exceptions are indicated through the CPT II codes, so no specific indication of what medical, patient, or systems factor needs to be provided. Despite some concern on the part of CMS that providers would use these exceptions inappropriately to falsely improve their reported quality of care, Topics in Practice Management
Figure 1. A: asthma measure codes. B: COPD measure codes.
initial data7 revealed that the exception codes were used for only 2.2% of reports. In addition to PQRI measures related to specific patient diagnoses, there is one “structural” measure, use of an electronic health record (EHR). A second structural measure, the use of electronic prescribing, isno longer part of PQRI and qualifies for an incentive additive to that of PQRI or more information on the e-prescribing incentive. (For more information on the electronic prescribing program, see http://www.cms. hhs.gov/erxincentive/.) The incentive for the use of electronic prescribing will gradually be reduced to 0% by 2014, and penalties for not using electronic prescribing begin in 2012, starting at 1.0% and rising to 2.0% in 2014. Two additional components of the PQRI were initiated for the 2008 reporting period. One was the acceptance of data from several approved registries. This was a welcome refinement because it allows the use of data that were already being reported to one of these registries as a part of ongoing quality improvement or pay-for-performance programs. One of the approved registries is the Society for Thoracic Surgeons. The second new component of PQRI in 2008 was the use of measures groups that allowed the reporting of several related measures together. Currently, there are seven measures groups, only two of which would seem relevant to chest physicians. One is the preventive care group, which would only be relevant to chest physicians who do a large amount of primary care. The other is the coronary artery bypass measures group, which is reportable only via the Society for Thoracic Surgery registry. www.chestjournal.org
Deciding Whether to Participate There are three potential reasons to participate in the PQRI program. Obviously, there is a potential to earn a financial incentive. In 2007, the average incentive per NPI for the 6-month reporting period was $635, and the average incentive per taxpayer identification number was $4,713. For the current full-year reporting period, one would expect incentives more than twice as high, due to the increased incentive from the original 1.5% in 2007 to the current 2.0%, as well as the increase from 6 months to 12 months of Medicare reimbursement on which the incentive is calculated. However, the incentive is somewhat offset by the increased billing cost associated with entering an increased number of CPT codes per claim, as well as the time and effort associated with implementing a system to collect the necessary data. A second potential reason for participation is that CMS will provide performance feedback to the participating providers, which could facilitate improved quality of care. Finally, participation now will prepare one for the future, when a program similar to PQRI is likely to be mandatory, results are likely to be publicly reported, and the financial rewards and penalties are likely to be greater. Choosing the Appropriate Measures There are several issues to consider when deciding which measures to report on. (See http://www.cms.hhs. gov/PQRI/Downloads/2009_PQRI_MeasuresList_ 030409.pdf for relevant downloads including a complete list of measures and a detailed list of all of the CHEST / 136 / 6 / DECEMBER, 2009
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measures and their technical specifications.) Obviously, the measure should be relevant to the physician’s practice. Most pulmonologists will find that the asthma and COPD measures are relevant to their outpatient practice. Both of these conditions have the added benefit that two measures can be reported for the same patient, which will lessen the reporting burden for most practices. For those who have a predominantly inpatient practice, potentially relevant measures include medication reconciliation at hospital discharge, catheter-related bloodstream infection prevention, and the community-acquired pneumonia measures. Note that the pneumonia measures are actually outpatient measures, so they only apply to services provided in the ED or the office. See Table 1 for a list of measures likely to be appropriate for pulmonologists and critical care physicians. Cardiologists and cardiothoracic surgeons will also find numerous measures related to both their inpatient and outpatient practices.8 Another consideration is the cost and efficiency of the billing system for practice. It might be tempting to select a measure that is relevant to only a small number of patients seen in the practice, so the additional coding and billing costs associated with PQRI can be minimized. However, doing so creates the risk that missing just a few patients lowers the reporting rate below the 80% required for the incentive payment. From a quality improvement standpoint, because CMS will report individual provider data back to the provider, one could consider reporting on a measure where there may be opportunities for improvement in the quality of care. Because there is no public reporting of the results, there would appear to be no negative consequences to this. Most physicians will wish to choose measures so that the reporting can easily be incorporated into their existing billing processes. Physicians should consider whether reporting on measures related to inpatient care or outpatient care will be easier to implement. For chest physicians in private practice, it may be easier to report on outpatient measures as opposed to attempting to implement a change in billing procedures in the less controlled inpatient environment, where office support is not available.
Implementing a Reporting System As with any other practice change, simply expecting the provider to remember to do the PQRI documentation is likely to fail. A specific system will need to be implemented. PQRI implementation tools from CMS can be found at http://www.cms.hhs.gov/ PQRI/Downloads/2009_PQRI_ImplementationGuide_ 062209_508.pdf and tools from the American Med1648
ical Association at http://www.ama-assn.org/go/ toolsMedicarePQRI. The best method for reporting on the PQRI measures will depend on the billing system currently in place in any given practice. At the author’s institution, billing is done by the provider, who circles the appropriate ICD-9-CM and CPT codes on a paper billing sheet. A PQRI sheet was created for the asthma measures and another for the COPD measures. The office staff was instructed to attach the blank PQRI sheet to the billing sheet for all fee-for-service Medicare patients, so that the physician would be reminded to fill in the PQRI data for the appropriate patients. Ideally, for those who electronically code their patient encounters, the system would automatically prompt the provider to enter the appropriate PQRI category II CPT codes whenever relevant CPT and ICD-9-CM codes are entered. For practices in which a billing specialist performs the coding based on review of the office note or consultation, providers will have to be careful to document in a manner that allows the coder to be able to determine the appropriate category II CPT code signifying performance of the measured process of care or the appropriate exception. Given these issues, as well as the technical problems encountered with PQRI detailed later, before a practice institutes a process for PQRI reporting, input should be sought from all of the personnel involved in the coding and billing process. It may also be advantageous to begin the reporting process a month or two before the beginning of the reporting period, so that any problems can be detected and addressed. Some measures need to be reported with each encounter (assessment of asthma symptoms); others only need to be documented once in a reporting period (spirometry for COPD). The ideal system would be able to avoid redundant data submission, although for many practices, this will be difficult to achieve.
Technical Aspects of PQRI Many billing software vendors have already begun incorporating the PQRI codes into their software. Because there have been new PQRI measures each year, the capabilities of the practice’s system should be checked before embarking on the PQRI. In addition, some billing software will not input a CPT code without a charge. CMS recommends that a very small charge such as 1 or 2 cents be submitted in that case, which will not be paid by CMS. In 2009 CMS continued to explore the feasibility of accepting PQRI data extracted directly from EHRs. Providers considering purchase of an EHR should inquire about the PQRI capabilities of the system being Topics in Practice Management
considered. In 2010, CMS plans to accept data reported from EHRs for 10 measures. It is important to note that CMS intends to phase out the current category II CPT code claims-based reporting system and move to a requirement that data be submitted from approved registries. The American College of Chest Physicians (ACCP) is actively planning for this eventuality through the ACCP Quality Improvement Registry (or AQuIRE), which uses a platform that has already been approved by CMS for PQRI reporting. Thus, participating providers would submit data to the ACCP Qualilty Improvement Registry, and these data would then be submitted to CMS. Such a system might make PQRI data submission easier for providers. Although the basic design of the PQRI program is straightforward, in 2007 48% of quality data submitted was invalid; clearly, implementation was not straightforward. CMS performed an analysis of the problems associated with PQRI reporting in 2007.9 One example of an invalid submission is if a category II CPT code is submitted and an appropriate service is coded, but the ICD-9-CM code is not appropriate for the measure being reported. An example would be if the diagnosis was coded as bronchospasm (511.9) instead of one of the asthma codes. Certain measures apply only to patients of a specific age. For example, the asthma measures do not apply to patients ⬎ 40 years of age. Some billing software systems also caused submission of invalid data. Many systems limit the number of diagnoses per claim to three diagnoses. If the appropriate diagnosis is the fourth one listed, it would not make it onto the claim. Other technical issues also commonly caused invalid submissions. In some cases, the category II CPT codes were reported on a separate claim from the billing and diagnosis codes. In others, the claim was missing an NPI, and therefore could not be attributed to a specific provider. Finally, some Medicare carriers apparently inadvertently cut off the bottom of some of the 1,500 claim forms, resulting in missing data. Summary The CMS PQRI program is a voluntary “pay for reporting” program that provides the opportunity for participating physicians to earn a bonus equal to 2% of their total annual Medicare reimbursement in
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return for submitting quality data on at least three measures relevant to their practice. For most physicians, it is likely that a PQRI reporting process can be integrated into their billing process without excessive resource use. Although the 2% bonus will not result in a huge windfall for many practices, participation now will prepare providers for the near future when similar reporting programs are likely to become mandatory and more dollars will be at stake. Acknowledgments Financial/nonfinancial disclosures: Dr. Metersky has served as a consultant to the Centers for Medicare and Medicaid Services and to Qualidigm (Connecticut’s Medicare Quality Improvement Organization) on various quality improvement and patient safety initiatives. His employer has received remuneration for some of these activities.
References 1 Committee on Redesigning Health Insurance Performance Measures, Payment and Performance Improvement Programs. Rewarding provider performance: aligning incentives in Medicare. Washington, DC: The National Academies Press, 2007 2 Centers for Medicare and Medicaid Services. 2005 Medicare “Pay for Performance (P4P)” initiatives. Available at: http://www. cms.hhs.gov/apps/media/press/release.asp?counter⫽1343. Accessed November 1, 2009 3 Baumann MH, Dellert E. Performance measures and pay for performance. Chest 2006; 129:188 –191 4 Metersky ML. Pay for performance. In: Manaker S, ed. Coding for chest medicine 2009. Northbrook, IL: American College of Chest Physicians, 2008; 343–352 5 Centers for Medicare and Medicaid Services. Physician quality reporting initiative. Available at: http://www.cms.hhs.gov/ pqri/. Accessed November 1, 2009 6 National Archives and Records Administration. Federal Register/Vol. 73, No. 224/Wednesday, November 19, 2008/Rules and Regulations 69817. Available at: http://www.aad.org/pm/ billing/medicare/_doc/2009%20CMS%20Final%20Rule%20re% 20Medicare%20Pathology%20Billing%20Section.pdf. Accessed November 1, 2009 7 Iowa Foundation for Medical Care. 2007 Physician quality reporting initiative (PQRI): preliminary participation, as of November 2007. West Des Moines, IA: Iowa Foundation for Medical Care, 2008 8 Centers for Medicare and Medicaid Services. Physician quality reporting initiative. Available at: http://www.cms.hhs.gov/PQRI/ Downloads/2009_PQRI_MeasuresList_030409.pdf. Accessed November 16, 2009 9 Centers for Medicare and Medicaid Services. Physician quality reporting initiative. Available at: http://www.cms.hhs.gov/PQRI/ Downloads/PQRI2007ReportExperience.pdf. Accessed April 24, 2009
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Topics in Practice Management
The Medicare Physician Quality Reporting Initiative What Do Chest Physicians Need to Know? Mark L. Metersky, MD, FCCP
Health-care consumers, payers, and regulatory agencies have become increasingly concerned about the rising cost and perceived deficiencies in the quality of health care in the United States. Pay-for-performance initiatives, otherwise known as value-based purchasing, are gathering political and public support as a method to address these problems. The Centers for Medicare and Medicaid Services is moving rapidly toward a system in which reimbursement is linked to quality of care. Serving as a first step, the Medicare Physician Quality Reporting Initiative (PQRI) is a program that rewards providers for reporting their performance on certain quality measures. Participating providers receive a bonus equal to 2% of their entire Medicare reimbursement for the calendar year if they successfully report on at least three measures for 80% of relevant patients seen during that year. The performance data are submitted via specifically designated Current Procedural Terminology II codes that are added to the usual codes submitted on the billing claim. Physicians should strongly consider participating in PQRI because it is likely to form the framework for future pay for performance, in which the dollars at stake may be much higher. (CHEST 2009; 136:1644 –1649) Abbreviations: ACCP ⫽ American College of Chest Physicians; CMS ⫽ Centers for Medicare and Medicaid Services; CPT ⫽ Current Procedural Terminology; EHR ⫽ electronic health record; ICD-9-CM ⫽ International Classification of Diseases, ninth revision, clinical modification; NPI ⫽ national provider identifier; PQRI ⫽ Physician Quality Reporting Initiative
of less than optimum quality and T hethecombination spiraling cost of medical care in the United States has led the Centers for Medicare and Medicaid Services (CMS), the Joint Commission for the Accreditation of Healthcare Organizations, managed care organizations, and large employers to search for new methods of reimbursing health-care providers, in hopes of encouraging the provision of higher quality and more cost-effective care. CMS has clearly Manuscript received January 25, 2009; revision accepted March 2, 2009. Affiliations: From the Division of Pulmonary and Critical Care Medicine, University of Connecticut School of Medicine, Farmington, CT. Correspondence to: Mark L. Metersky, MD, FCCP, Division of Pulmonary and Critical Care Medicine, University of Connecticut Health Center, 263 Farmington Ave, Farmington, CT 06030-1321; e-mail: [email protected] © 2009 American College of Chest Physicians. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/site/ misc/reprints.xhtml). DOI: 10.1378/chest.09-0193 1644
demonstrated its intention to change the reimbursement paradigm from the fee-for-service system that is currently used to a pay-for-performance, or valuebased purchasing, scheme.1,2 Implementing this type of reimbursement scheme will require that providers be regularly assessed with regard to their For editorial comment see page 1452 quality of care by the use of validated performance measures.3 As a first step, CMS implemented the Physician Quality Reporting Initiative (PQRI) in 2007.4,5 In this optional program, providers receive financial compensation in return for reporting data regarding their performance on certain quality measures. Although it was previously unclear how long this program was going to last, at the end of 2008 Congress passed legislation making it “permanent.”6 Approximately 16% of eligible providers (109,000) participated in the PQRI during the 2007 measureTopics in Practice Management
ment period, of whom 52% received a financial incentive. In the future, it is likely that the PQRI will become mandatory for physicians caring for Medicare patients, and it is expected that the program will move toward rewarding providers for the quality of care being provided, not just for reporting the quality of care.3 Financial penalties for reporting poor quality of care are also likely to ensue. The purpose of this article is to review the CMS PQRI program so that physicians can participate effectively as it is currently structured and can be prepared for the future, when PQRI and programs like it will assume greater importance.
Structure of the PQRI Health-care providers, including but not limited to physicians, nurse practitioners, and physicians’ assistants, who see fee-for-service Medicare patients may participate in PQRI. Those participating must choose a minimum of three relevant quality measures to report on to be eligible for a financial bonus. Providers who successfully report on 80% of appropriate patients for each of three measures will receive the bonus. Thus, physicians receive bonus payments for reporting performance or nonperformance of the recommended process of care; incentives are not currently based on how often physicians provided the recommended care. There is no public reporting of the results; however, CMS has indicated that it is planning to publicly report whether or not individual physicians participated in PQRI during 2009. The bonus payment for the 2009 reporting period is 2.0% of the total Medicare reimbursement received during the January 1, 2009, to December 31, 2009, calendar year. This will not change for 2010. A physician’s performance is calculated based on his or her individual performance, linked to their national provider identifier (NPI), even if they belong to a group practice or are an employee of another entity, such as a hospital. However, the bonus is payable to the taxpayer identification number under which the physician is billing CMS. For the first time in 2010, a group practice can choose for the performance of the group as a whole to be the unit of measurement, as opposed to the performance of the individual providers. This means that if the group reaches the performance target of 80%, the group receives the 2% bonus, even if some providers are under the target. Although the PQRI program has not been without glitches, the basic design of the program is admirable in its simplicity. Providers do not have to register to participate in the program, nor do they have to prospectively inform CMS of which measures they www.chestjournal.org
wish to report. Participating physicians select three or more of the measures relevant to their practice. Physicians who choose to submit data on more than three measures will receive a bonus if they reach the 80% reporting threshold for three measures. See Table 1 for a list of the measures most relevant to pulmonary and critical care physicians. The relevant diagnoses for each measure are defined by a list of International Classification of Diseases, ninth revision, clinical modification (ICD-9-CM) codes that identify the patient as having the relevant clinical condition. For many of the diagnoses, including pneumonia, COPD and asthma, there are several ICD-9-CM codes that are relevant. When a claim is submitted for a patient with an appropriate diagnosis, one or more category II Current Procedural Terminology (CPT) codes are submitted in addition to the usual CPT codes that providers use to identify the specific evaluation and management service or procedure that is being billed. Category II CPT codes were developed to represent processes of care related to specific performance measures, as well as to represent any exceptions, reasons that a service was not provided. Unlike regular CPT codes, they are not associated with any charge. See Figure 1A and B for an example of all the category II CPT codes related to the asthma and COPD measures, respectively. Once a category II CPT code associated with a specific measure is reported, CMS will assume that all patients with the relevant diagnosis seen by that provider are eligible for reporting. For example, if a provider reports: CPT II 3023F (spirometry results documented and reviewed) for a COPD patient (ICD-9-CM code 496), CMS will know that that physician is reporting on that measure and will include all fee-for-service Medicare COPD patients seen in an outpatient setting by that provider during the measurement period. These patients are placed in the reporting physicians’ denominator when a claim for a relevant service (identified by the CPT code) is submitted with any of the ICD-9-CM codes that identify the patient as having COPD. The provider will then have to report an appropriate CPT II code for ⱖ 80% of COPD patients for whom they submit a claim to CMS to reach the target for that measure. Note that this means the provider is not responsible for reporting on a patient if the patient is not seen during that billing year. Also, most measures are linked to specific categories of service. For example, the asthma measures of controller use and assessment of symptoms are linked to outpatient evaluation and management CPT codes only. A provider will not get credit for reporting one of these codes linked to a CHEST / 136 / 6 / DECEMBER, 2009
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Table 1—Relevancy Measures Included in the 2009 PQRI and Accompanying CPT Category II Codes Indicating Performance of the Recommended Service COPD Measure 51: COPD: spirometry evaluation Percentage of patients ⱖ 18 yr of age with a diagnosis of COPD who had spirometry evaluation results documented CPT II 3023F: spirometry results documented and reviewed Measure 52: COPD: bronchodilator therapy Percentage of patients ⱖ 18 yr of age with a diagnosis of COPD and who have an FEV1/FVC ⬍ 70% and have symptoms who were prescribed an inhaled bronchodilator CPT II 4025F: inhaled bronchodilator prescribed And CPT II 3025F: spirometry test results demonstrate FEV1/FVC ratio ⬍ 70% with COPD symptoms (eg, dyspnea, cough/sputum, wheezing) Asthma Measure 53: asthma: pharmacologic therapy Percentage of patients 5 to 40 yr of age with a diagnosis of mild, moderate, or severe persistent asthma who were prescribed either the preferred long-term control medication (inhaled corticosteroid) or an acceptable alternative treatment CPTII 4015F: persistent asthma, preferred long-term control medication, or acceptable alternative treatment prescribed And CPTII 1038F: Persistent asthma (mild, moderate, or severe) Measure 64: asthma assessment Percentage of patients 5 to 40 yr of age with a diagnosis of asthma who were evaluated during at least one office visit within 12 mo for the frequency (numeric) of daytime and nocturnal asthma symptoms CPT II 1005F: asthma symptoms evaluated (includes physician documentation of numeric frequency of symptoms or patient completion of an asthma assessment tool/survey/questionnaire) Pneumonia Measure 56: vital signs for community-acquired bacterial pneumonia Percentage of patients ⱖ 18 yr of age with a diagnosis of community-acquired bacterial pneumonia with vital signs documented and reviewed CPT II 2010F: vital signs (temperature, pulse, respiratory rate, and blood pressure) documented and reviewed Measure 57: assessment of oxygen saturation for community-acquired bacterial pneumonia* Percentage of patients ⱖ 18 yr of age with a diagnosis of community-acquired bacterial pneumonia with oxygen saturation documented and reviewed CPT II 3028F: oxygen saturation results documented and reviewed Measure 58: assessment of mental status for community-acquired bacterial pneumonia Percentage of patients ⱖ 18 yr of age with a diagnosis of community-acquired bacterial pneumonia with mental status assessed CPT II 2014F: mental status assessed Measure 59: empiric antibiotic for community-acquired bacterial pneumonia Percentage of patients ⱖ 18 yr of age with a diagnosis of community-acquired bacterial pneumonia with an appropriate empiric antibiotic prescribed CPT II 4045F: appropriate empiric antibiotic prescribed Measure 76: prevention of catheter-related bloodstream infections: CVC insertion protocol Percentage of patients, regardless of age, who undergo CVC insertion for whom CVC was inserted with all elements of maximal sterile barrier technique (cap and mask and sterile gown and sterile gloves and a large sterile sheet and hand hygiene and 2% chlorhexidine for cutaneous antisepsis or acceptable alternative antiseptics per current guideline) followed CPT II 6030F: all elements of maximum sterile barrier technique followed Other codes for documenting exceptions and nonperformance exist for each measure. Adapted from Baumann and Dellert.3 CVC ⫽ central venous catheter. *Although oxygen assessment for patients with community-acquired pneumonia remains a measure for the 2009 PQRI program, it is no longer one of the CMS core measures for patients admitted to the hospital with pneumonia.
claim for an influenza vaccination, for example. Similarly, the measures related to inpatient hospital care are not linked to CPT codes that identify outpatient services. CMS is aware that for many measures a performance target of 100% is not achievable and that for some would not even be desirable because it would lead to inappropriate overuse. Thus, there are category CPT II codes that allow documentation of exceptions, that is, reasons that a measured element of care was not provided. These include medical 1646
factors, patient-related factors, and systems factors. For example, a medical reason for not providing an influenza vaccine would be egg allergy, a patientrelated factor would be patient refusal, and a systems factor would be lack of available vaccine. Note that these exceptions are indicated through the CPT II codes, so no specific indication of what medical, patient, or systems factor needs to be provided. Despite some concern on the part of CMS that providers would use these exceptions inappropriately to falsely improve their reported quality of care, Topics in Practice Management
Figure 1. A: asthma measure codes. B: COPD measure codes.
initial data7 revealed that the exception codes were used for only 2.2% of reports. In addition to PQRI measures related to specific patient diagnoses, there is one “structural” measure, use of an electronic health record (EHR). A second structural measure, the use of electronic prescribing, isno longer part of PQRI and qualifies for an incentive additive to that of PQRI or more information on the e-prescribing incentive. (For more information on the electronic prescribing program, see http://www.cms. hhs.gov/erxincentive/.) The incentive for the use of electronic prescribing will gradually be reduced to 0% by 2014, and penalties for not using electronic prescribing begin in 2012, starting at 1.0% and rising to 2.0% in 2014. Two additional components of the PQRI were initiated for the 2008 reporting period. One was the acceptance of data from several approved registries. This was a welcome refinement because it allows the use of data that were already being reported to one of these registries as a part of ongoing quality improvement or pay-for-performance programs. One of the approved registries is the Society for Thoracic Surgeons. The second new component of PQRI in 2008 was the use of measures groups that allowed the reporting of several related measures together. Currently, there are seven measures groups, only two of which would seem relevant to chest physicians. One is the preventive care group, which would only be relevant to chest physicians who do a large amount of primary care. The other is the coronary artery bypass measures group, which is reportable only via the Society for Thoracic Surgery registry. www.chestjournal.org
Deciding Whether to Participate There are three potential reasons to participate in the PQRI program. Obviously, there is a potential to earn a financial incentive. In 2007, the average incentive per NPI for the 6-month reporting period was $635, and the average incentive per taxpayer identification number was $4,713. For the current full-year reporting period, one would expect incentives more than twice as high, due to the increased incentive from the original 1.5% in 2007 to the current 2.0%, as well as the increase from 6 months to 12 months of Medicare reimbursement on which the incentive is calculated. However, the incentive is somewhat offset by the increased billing cost associated with entering an increased number of CPT codes per claim, as well as the time and effort associated with implementing a system to collect the necessary data. A second potential reason for participation is that CMS will provide performance feedback to the participating providers, which could facilitate improved quality of care. Finally, participation now will prepare one for the future, when a program similar to PQRI is likely to be mandatory, results are likely to be publicly reported, and the financial rewards and penalties are likely to be greater. Choosing the Appropriate Measures There are several issues to consider when deciding which measures to report on. (See http://www.cms.hhs. gov/PQRI/Downloads/2009_PQRI_MeasuresList_ 030409.pdf for relevant downloads including a complete list of measures and a detailed list of all of the CHEST / 136 / 6 / DECEMBER, 2009
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measures and their technical specifications.) Obviously, the measure should be relevant to the physician’s practice. Most pulmonologists will find that the asthma and COPD measures are relevant to their outpatient practice. Both of these conditions have the added benefit that two measures can be reported for the same patient, which will lessen the reporting burden for most practices. For those who have a predominantly inpatient practice, potentially relevant measures include medication reconciliation at hospital discharge, catheter-related bloodstream infection prevention, and the community-acquired pneumonia measures. Note that the pneumonia measures are actually outpatient measures, so they only apply to services provided in the ED or the office. See Table 1 for a list of measures likely to be appropriate for pulmonologists and critical care physicians. Cardiologists and cardiothoracic surgeons will also find numerous measures related to both their inpatient and outpatient practices.8 Another consideration is the cost and efficiency of the billing system for practice. It might be tempting to select a measure that is relevant to only a small number of patients seen in the practice, so the additional coding and billing costs associated with PQRI can be minimized. However, doing so creates the risk that missing just a few patients lowers the reporting rate below the 80% required for the incentive payment. From a quality improvement standpoint, because CMS will report individual provider data back to the provider, one could consider reporting on a measure where there may be opportunities for improvement in the quality of care. Because there is no public reporting of the results, there would appear to be no negative consequences to this. Most physicians will wish to choose measures so that the reporting can easily be incorporated into their existing billing processes. Physicians should consider whether reporting on measures related to inpatient care or outpatient care will be easier to implement. For chest physicians in private practice, it may be easier to report on outpatient measures as opposed to attempting to implement a change in billing procedures in the less controlled inpatient environment, where office support is not available.
Implementing a Reporting System As with any other practice change, simply expecting the provider to remember to do the PQRI documentation is likely to fail. A specific system will need to be implemented. PQRI implementation tools from CMS can be found at http://www.cms.hhs.gov/ PQRI/Downloads/2009_PQRI_ImplementationGuide_ 062209_508.pdf and tools from the American Med1648
ical Association at http://www.ama-assn.org/go/ toolsMedicarePQRI. The best method for reporting on the PQRI measures will depend on the billing system currently in place in any given practice. At the author’s institution, billing is done by the provider, who circles the appropriate ICD-9-CM and CPT codes on a paper billing sheet. A PQRI sheet was created for the asthma measures and another for the COPD measures. The office staff was instructed to attach the blank PQRI sheet to the billing sheet for all fee-for-service Medicare patients, so that the physician would be reminded to fill in the PQRI data for the appropriate patients. Ideally, for those who electronically code their patient encounters, the system would automatically prompt the provider to enter the appropriate PQRI category II CPT codes whenever relevant CPT and ICD-9-CM codes are entered. For practices in which a billing specialist performs the coding based on review of the office note or consultation, providers will have to be careful to document in a manner that allows the coder to be able to determine the appropriate category II CPT code signifying performance of the measured process of care or the appropriate exception. Given these issues, as well as the technical problems encountered with PQRI detailed later, before a practice institutes a process for PQRI reporting, input should be sought from all of the personnel involved in the coding and billing process. It may also be advantageous to begin the reporting process a month or two before the beginning of the reporting period, so that any problems can be detected and addressed. Some measures need to be reported with each encounter (assessment of asthma symptoms); others only need to be documented once in a reporting period (spirometry for COPD). The ideal system would be able to avoid redundant data submission, although for many practices, this will be difficult to achieve.
Technical Aspects of PQRI Many billing software vendors have already begun incorporating the PQRI codes into their software. Because there have been new PQRI measures each year, the capabilities of the practice’s system should be checked before embarking on the PQRI. In addition, some billing software will not input a CPT code without a charge. CMS recommends that a very small charge such as 1 or 2 cents be submitted in that case, which will not be paid by CMS. In 2009 CMS continued to explore the feasibility of accepting PQRI data extracted directly from EHRs. Providers considering purchase of an EHR should inquire about the PQRI capabilities of the system being Topics in Practice Management
considered. In 2010, CMS plans to accept data reported from EHRs for 10 measures. It is important to note that CMS intends to phase out the current category II CPT code claims-based reporting system and move to a requirement that data be submitted from approved registries. The American College of Chest Physicians (ACCP) is actively planning for this eventuality through the ACCP Quality Improvement Registry (or AQuIRE), which uses a platform that has already been approved by CMS for PQRI reporting. Thus, participating providers would submit data to the ACCP Qualilty Improvement Registry, and these data would then be submitted to CMS. Such a system might make PQRI data submission easier for providers. Although the basic design of the PQRI program is straightforward, in 2007 48% of quality data submitted was invalid; clearly, implementation was not straightforward. CMS performed an analysis of the problems associated with PQRI reporting in 2007.9 One example of an invalid submission is if a category II CPT code is submitted and an appropriate service is coded, but the ICD-9-CM code is not appropriate for the measure being reported. An example would be if the diagnosis was coded as bronchospasm (511.9) instead of one of the asthma codes. Certain measures apply only to patients of a specific age. For example, the asthma measures do not apply to patients ⬎ 40 years of age. Some billing software systems also caused submission of invalid data. Many systems limit the number of diagnoses per claim to three diagnoses. If the appropriate diagnosis is the fourth one listed, it would not make it onto the claim. Other technical issues also commonly caused invalid submissions. In some cases, the category II CPT codes were reported on a separate claim from the billing and diagnosis codes. In others, the claim was missing an NPI, and therefore could not be attributed to a specific provider. Finally, some Medicare carriers apparently inadvertently cut off the bottom of some of the 1,500 claim forms, resulting in missing data. Summary The CMS PQRI program is a voluntary “pay for reporting” program that provides the opportunity for participating physicians to earn a bonus equal to 2% of their total annual Medicare reimbursement in
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return for submitting quality data on at least three measures relevant to their practice. For most physicians, it is likely that a PQRI reporting process can be integrated into their billing process without excessive resource use. Although the 2% bonus will not result in a huge windfall for many practices, participation now will prepare providers for the near future when similar reporting programs are likely to become mandatory and more dollars will be at stake. Acknowledgments Financial/nonfinancial disclosures: Dr. Metersky has served as a consultant to the Centers for Medicare and Medicaid Services and to Qualidigm (Connecticut’s Medicare Quality Improvement Organization) on various quality improvement and patient safety initiatives. His employer has received remuneration for some of these activities.
References 1 Committee on Redesigning Health Insurance Performance Measures, Payment and Performance Improvement Programs. Rewarding provider performance: aligning incentives in Medicare. Washington, DC: The National Academies Press, 2007 2 Centers for Medicare and Medicaid Services. 2005 Medicare “Pay for Performance (P4P)” initiatives. Available at: http://www. cms.hhs.gov/apps/media/press/release.asp?counter⫽1343. Accessed November 1, 2009 3 Baumann MH, Dellert E. Performance measures and pay for performance. Chest 2006; 129:188 –191 4 Metersky ML. Pay for performance. In: Manaker S, ed. Coding for chest medicine 2009. Northbrook, IL: American College of Chest Physicians, 2008; 343–352 5 Centers for Medicare and Medicaid Services. Physician quality reporting initiative. Available at: http://www.cms.hhs.gov/ pqri/. Accessed November 1, 2009 6 National Archives and Records Administration. Federal Register/Vol. 73, No. 224/Wednesday, November 19, 2008/Rules and Regulations 69817. Available at: http://www.aad.org/pm/ billing/medicare/_doc/2009%20CMS%20Final%20Rule%20re% 20Medicare%20Pathology%20Billing%20Section.pdf. Accessed November 1, 2009 7 Iowa Foundation for Medical Care. 2007 Physician quality reporting initiative (PQRI): preliminary participation, as of November 2007. West Des Moines, IA: Iowa Foundation for Medical Care, 2008 8 Centers for Medicare and Medicaid Services. Physician quality reporting initiative. Available at: http://www.cms.hhs.gov/PQRI/ Downloads/2009_PQRI_MeasuresList_030409.pdf. Accessed November 16, 2009 9 Centers for Medicare and Medicaid Services. Physician quality reporting initiative. Available at: http://www.cms.hhs.gov/PQRI/ Downloads/PQRI2007ReportExperience.pdf. Accessed April 24, 2009
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