Key Facts: Medicare Physician Quality Reporting Initiative (PQRI) | Med Law Blog | Tucker Arensberg, P. C.

KEY FACTS: PHYSICIAN QUALITY REPORTING INITIATIVE (PQRI)

PQRI is a precursor to Medicare pay for performance (P4P) or quality incentives established by the Tax Relief and Healthcare Act of 2006 (TRHCA). The first quality reporting period will be July 1, 2007 through December 31, 2007.

Payment Amount: Congress budgeted $1.35 billion but the payment amount per provider is;

(1) Subject to the number of participating/reporting physicians;

(2) Limited to no more than 1.5% of the total allowed charges for covered services provided during the reporting period, i.e., 7/1/07 – 12/31/07;

(3) Will be paid in a single consolidated payment in “mid 2008.”

Eligible Providers: Doctors, Dentists, Chiropractors, Podiatrists, Optometrists, PT, OT, PA, CRNA, CNS, NM, Psychologist, Dietician.

Eligible Services: CMS has identified 74 measures for 2007 PQRI; eligible services for 2008 are being developed.

Procedure and Reporting Thresholds: Providers should select services applicable to their patient panels. In order to “successfully report” and receive the bonus payments, certain reporting thresholds must be met:

(1) When 3 or fewer measures are selected, providers must report in at least 80% of the potential cases.

(2) When more than 3 measures are selected, the 80% threshold must be satisfied for at least 3 measures.

Sample instructions for 4 measures follows:

2007 Physician Quality Reporting Initiative (PQRI)Measure Specifications

+Measure #1 Hemoglobin Al c Poor Control in Type 1 or 2 Diabetes Mellitus

DESCRIPTION:

Percentage of patients aged 18 through 75 years with diabetes (type 1 or type 2) who had most recent hemoglobin Al c greater than 9.0%

INSTRUCTIONS:

This measure is to be reported a minimum of once per reporting period for patients seen during the reporting period. The performance period for this measure is 12 months. The most recent quality code submitted will be used for performance calculation. It is anticipated that clinicians who provide services for the primary management of diabetes mellitus will submit this measure.

This measure can be reported using CPT Category II codes:

ICD-9 diagnosis codes, CPT E/M service codes, G-codes, and patient demographics (age, gender, etc..) are used to identify patients who are included in the measure’s denominator. CPT Category II codes are used to report the numerator of the measure.

When reporting the measure, submit the listed ICD-9 diagnosis codes, CPT E/M service codes or G-codes, and the appropriate CPT Category II code OR the CPT Category II code with the modifier. The reporting modifier allowed for this measure is: 8P- reasons not otherwise specified. There are no allowable performance exclusions for this measure.

NUMERATOR:

Patients with most recent hemoglobin Alc level > 9.0%

Numerator Instructions: This is a poor control measure. A lower rate indicates better performance (e.g., low rates of poor control indicate better care)

Numerator Coding:

Most Recent Hemoglobin Al c Performed

CPT II 3046F: Most recent hemoglobin Alc level > 9.0% OR

CPT II 3044F: Most recent hemoglobin Alc level < 7.0% OR

CPT II 3045F: Most recent hemoglobin Alc level 7.0% to 9.0%

Hemoglobin Al c not Performed, Reason Not Specified

Append a reporting modifier (8P) to CPT Category II code 3046F to report circumstances when the action described in the numerator is not performed and the reason is not otherwise specified.

• 8P: Hemoglobin Alc level was not performed during the performance period (12 months), reason not otherwise specified

DENOMINATOR:

Patients aged 18-75 years with the diagnosis of diabetes

Denominator Coding:

An ICD-9 diagnosis code for diabetes and a CPT E/M service code or G-code are required to identify patients for denominator inclusion.

ICD-9 diagnosis codes: 250.00, 250.01, 250.02, 250.03, 250.10, 250.11, 250.12, 250.13, 250.20, 250.21, 250.22, 250.23, 250.30, 250.31, 250.32, 250.33, 250.40, 250.41, 250.42, 250.43, 250.50, 250.51, 250.52, 250.53, 250.60, 250.61, 250.62, 250.63, 250.70, 250.71, 250.72, 250.73, 250.80, 250.81, 250.82, 250.83, 250.90, 250.91, 250.92, 250.93, 648.00, 648.01, 648.02, 648.03, 648.04

AND

CPT ERA service codes or G-codes: 97802, 97803, 97804, 99201, 99202, 99203, 99204, 99205, 99211,99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99343, 99324, 99344, 99325, 99345, 99326, 99347, 99327, 99348, 99328, 99349, 99334, 99350, 99335, G0270, 99336, G0271, 99337, 99341, 99342,

RATIONALE:

Intensive therapy of glycosylated hemoglobin (Al c) reduces the risk of microvascular complications.

CLINICAL RECOMMENDATION STATEMENTS:

A glycosylated hemoglobin should be performed during an initial assessment and during follow-up assessments, which should occur at no longer than three-month intervals. (AACE/ACE)

The Al c should be universally adopted as the primary method of assessment of glycemic control. On the basis of data from multiple interventional trials, the target for attainment of glycemic control should be Al c values 6.5%. (AACE/ACE)

Obtain a glycosylated hemoglobin during an initial assessment and then routinely as part of continuing care. In the absence of well-controlled studies that suggest a definite testing protocol, expert opinion recommends glycosylated hemoglobin be obtained at least twice a year in patients who are meeting treatment goals and who have stable glycemic control and more frequently (quarterly assessment) in patients whose therapy was changed or who are not meeting glycemic goals. (Level of evidence: E) (ADA)

Because different assays can give varying glycated hemoglobin values, the ADA recommends that laboratories only use assay methods that are certified as traceable to the Diabetes Control and Complications Trial Al c reference method. The ADA’s goal for glycemic control is Al c <7%. (Level of evidence: B) (ADA)

Monitor and treat hyperglycemia, with a target Al C of 7%, but less stringent goals for therapy may be appropriate once patient preferences, diabetes severity, life expectancy and functional status have been considered. (AGS)

¨Measure #2: Low Density Lipoprotein Control in Type 1 or 2 Diabetes Mellitus

DESCRIPTION:

Percentage of patients aged 18 through 75 years with diabetes (type 1 or type 2) who had most recent LDL-C level in control (less than 100 mg/dl)

INSTRUCTIONS:

This measure can be reported using CPT Category II codes:

ICD-9 diagnosis codes, CPT E/M service codes, G-codes, and patient demographics (age, gender, etc.) are used to identify patients who are included in the measure’s denominator. CPT Category II codes are used to report the numerator of the measure.

When reporting the measure, submit the listed ICD-9 diagnosis codes, CPT E/M service codes or G-codes, and the appropriate CPT Category II code OR the CPT Category II code with the modifier. The reporting modifier allowed for this measure is: 8P- reasons not otherwise specified. There are no allowable performance exclusions for this measure.

NUMERATOR:

Patients with most recent LDL-C < 100 mg/dL

Numerator Coding:

Most Recent LDL-C Performed

CPT II 3048F: Most recent LDL-C < 100 mg/dL

CPT II 3049F: Most recent LDL-C 100-129 mg/dL

CPT II 3050F: Most recent LDL-C 130 mg/dL

LDL-C Level not Performed, Reason Not Specified

Append a reporting modifier (8P) to CPT Category II code 3048F to report circumstances when the action described in the numerator is not performed and the reason is not otherwise specified.

• 8P: LDL-C was not performed during the performance period (12 months), reason not otherwise specified

DENOMINATOR:

Patients aged 18-75 years with the diagnosis of diabetes

Denominator Coding:

An ICD-9 diagnosis code for diabetes and a CPT E/M service code or G-code are required to identify patients for denominator inclusion.

AND

CPT EIM service codes or G-codes: 97802, 97803, 97804, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99343, 99324, 99344, 99325, 99345, 99326, 99347, 99327, 99348, 99328, 99349, 99334, 99350, 99335, G0270, 99336, G0271, 99337, 99341, 99342

RATIONALE:

Persons with diabetes are at increased risk for coronary heart disease (CHD). Lowering serum cholesterol levels can reduce the risk for CHD events.

CLINICAL RECOMMENDATION STATEMENTS:

A fasting lipid profile should be obtained during an initial assessment, each follow-up assessment, and annually as part of the cardiac-cerebrovascular-peripheral vascular module. (AACE/ACE)

A fasting lipid profile should be obtained as part of an initial assessment. Adult patients with diabetes should be tested annually for lipid disorders with fasting serum cholesterol, triglycerides, HDL cholesterol, and calculated LDL cholesterol measurements. If values fall in lower-risk levels, assessments may be repeated every two years. (Level of evidence: E) (ADA)

Patients who do not achieve lipid goals with lifestyle modifications require pharmacological therapy. Lowering LDL cholesterol with a statin is associated with a reduction in cardiovascular events. (Level of evidence: A)

Lipid-lowering therapy should be used for secondary prevention of cardiovascular mortality and morbidity for all patients with known coronary artery disease and type 2 diabetes. (ACP)

Statins should be used for primary prevention against macrovascular complications in patients with type 2 diabetes and other cardiovascular risk factors.

Once lipid-lowering therapy is initiated, patients with type 2 diabetes mellitus should be taking at least moderate doses of a statin.

Older persons with diabetes are likely to benefit greatly from cardiovascular risk reduction, therefore monitor and treat hypertension and dyslipidemias. (AGS)

¨Measure #3: High Blood Pressure Control in Type 1 or 2 Diabetes Mellitus

DESCRIPTION:

Percentage of patients aged 18 through 75 years with diabetes (type 1 or type 2) who had most recent blood pressure in control (less than 140/80 mm Hg)

INSTRUCTIONS:

This measure can be reported using either CPT Category II codes:

When reporting the measure, submit the listed ICD-9 diagnosis codes, CPT E/M service codes or G-codes, and the appropriate CPT Category II codes OR the CPT Category II code with the modifier. The reporting modifier allowed for this measure is: 8P- reasons not otherwise specified. There are no allowable performance exclusions for this measure.

NUMERATOR:

Patients whose most recent blood pressure < 140/80 mm Hg

Numerator Instructions: To describe both systolic and diastolic values, two codes must be reported for this measure. For the systolic blood pressure value, report one of the systolic codes; for the diastolic blood pressure value, report one of the diastolic codes. If there are multiple blood pressures on the same date of service, use the lowest systolic and lowest diastolic blood pressure on that date as the representative blood pressure.

Numerator Coding:

Most Recent Blood Pressure Measurement Performed

Systolic codes

CPT II 3074F: Most recent systolic blood pressure < 130 mm Hg

CPT II 3075F: Most recent systolic blood pressure 130 to 139 mm Hg

CPT II 3077F: Most recent systolic blood pressure > 140 mm Hg

AND

Diastolic codes

CPT II 3078F: Most recent diastolic blood pressure < 80 mm Hg OR

CPT II 3079F: Most recent diastolic blood pressure 80-89 mm Hg

CPT II 3080F: Most recent diastolic blood pressure > 90 mm Hg

Blood Pressure Measurement not Performed, Reason Not Specified

Append a reporting modifier (8P) to CPT Category II code 2000F to report circumstances when the action described in the numerator is not performed and the reason is not otherwise specified.

• 8P: No documentation of blood pressure measurement, reason not otherwise specified

DENOMINATOR:

Patients aged 18-75 years with the diagnosis of diabetes

Denominator Coding:

An ICD-9 diagnosis code for diabetes and a CPT E/M service code are required to identify patients for denominator inclusion.

AND

CPT UM service codes: 97802, 97803, 97804, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99324, 99344, 99325, 99345, 99326, 99347, 99327, 99348, 99328, 99349, 99334, 99350, 99335, G0270, 99336, G0271, 99337, 99341, 99342, 99343

RATIONALE:

Intensive control of blood pressure in patients with diabetes reduces diabetes complications, diabetes-related deaths, strokes, heart failure, and microvascular complications.

CLINICAL RECOMMENDATION STATEMENTS:

Recommends that a blood pressure determination during the initial evaluation, including orthostatic evaluation, be included in the initial and every interim physical examination. (AACE/ACE)

Blood pressure control must be a priority in the management of persons with hypertension and type 2 diabetes. (ACP)

Blood pressure should be measured at every routine diabetes visit. Patients found to have systolic blood pressure >130 mmHg or diastolic >80 mmHg should have blood pressure confirmed on a separate day. Orthostatic measurement of blood pressure should be performed to assess for the presence of autonomic neuropathy. (Level of Evidence: E) (ADA)

Older persons with diabetes are likely to benefit greatly from cardiovascular risk reduction, therefore monitor and treat hypertension and dyslipidemias. (AGS)

Measurement of blood pressure in the standing position is indicated periodically, especially in those at risk for postural hypotension. At least two measurements should be made and the average

recorded. After BP is at goal and stable, follow-up visits can usually be at 3- to 6-month intervals. Comorbidities such as heart failure, associated diseases such as diabetes, and the need for laboratory tests influence the frequency of visits. (JNC)

All individuals should be evaluated during health encounters to determine whether they are at increased risk of having or of developing chronic kidney disease. This evaluation of risk factors should include blood pressure measurement. (NKF)

Additional information is available as follows:

(1) CMS PQRI Link: http://www.cms.hhs.gov/PQRI/

(2) Three National Provider teleconferences; see:

parta-education@highmarkmedicarservices.com