Develop a System to Deliver the Best Bang for Your PQRI Buck

Gastroenterology Coding Alert

Develop a System to Deliver the Best Bang for Your PQRI Buck

Published on Mon Mar 23, 2009

A coder shares lessons learned from the first two years.

If you really want that 2 percent bonus for taking part in Medicare's Physician Quality Reporting Initiative, your whole office must buy in to the effort, and you need a plan to boost your chances to earn that extra money, our experts say.

There's no secret formula to winning the PQRI sweepstakes, says Tracy Helget, CPC, of Medical Associates of Manhattan in Manhattan, Kan., "but you need to develop a system that all providers and nurses can follow." Helget's office has been taking part in PQRI since its inception in 2007.

Helget is using lessons learned from her first year's PQRI reports to develop a system she hopes will enable all of her 17 providers (including a gastroenterologist) to qualify for the bonus in 2009.

Remember: To qualify for the PQRI bonus, your provider must report on 80 percent of qualifying visits on at least three criteria.

Get in Front of PQRI Now

Helget breaks it down for you:

Lesson 1: Identify all your Medicare fee-schedule patients. These should include the replacement Medicare plans, such as Humana Gold and Advantra Medicare. This may seem obvious, but if you miss a qualifying patient on the front end, you can't catch up later, because the PQRI code must accompany the appropriate E/M or procedure code when you report.

Lesson 2: Do your homework to keep the labor down for the rest of the year. "Don't report on what you see the most; this will require way too much additional paperwork," Helget says.

Narrow your list: Before you get started, review the qualifying criteria of each measure, Helget says. Eliminate any that would never apply to your practice. Eliminate the next set of measures based on diagnosis codes. Then choose five to report. You only need to successfully report three criteria, but five gives you room for error, Helget says.

If your billing system is capable, run reports based on diagnosis code, limited to the Medicare carriers, of the E/M visits you've performed in the past year. Most of the PQRI measures require an E/M visit as qualifying criteria.

Of these, choose your PQRI based on diagnosis codes that you see only a few of each year. "I recommend to our providers that they choose the PQRI that had fewer than 10 reportable incidents in 2007."

Minimize paperwork: If it works out right, Helget says, each provider should have to complete fewer than 50 reports over the year to qualify for the bonus. "It isn't foolproof," she says, but it's a place to start.

Lesson 3: Make it a team project. The front desk needs to flag the Medicare patients at the time of the visit. The nurses and providers need to identify the diagnosis criteria that will qualify the visit. If your physician forgets to complete the report or the report gets separated from the charge-billing information, Helget says, your opportunity is gone.

"All staff will have to be diligent to make it work," Helget says.

Patience, Thoroughness Are Keys to Success

Dealing with complexity and bureaucracy are the two big PQRI challenges, Helget says. "Many providers feel the PQRI reporting is too confusing and overwhelming so they won't attempt it," she says.

Another frustration is not knowing your results until it's too late to correct your processes. CMS's gears grind slowly. "Unfortunately, the (Medicare) reports were not available to us early enough to help with changes for the 2008 reporting year," Helget says. "Having the first year's reports has definitely been helpful in finding a direction to move in for the next year."

How to Do PQRI

You have to do a little extra coding for PQRI participation, says Caral Edelberg, CPC, CCS-P, CHC, president of Medical Management Resources for TeamHealth in Jacksonville, Fla. "There are specific PQRI quality-data codes associated with each of the PQRI measures," she says. The PQRI quality-data codes are mostly CPT Category II codes, located in the back of CPT 2009 and in Appendix H, where CPT lists the measures alphabetically by clinical condition or topic. PQRI relies on some HCPCS codes, too. Here's the PQRI process for each patient your office sees:

鈥� Check to make sure he is a Medicare fee-schedule patient

鈥� Review documentation to determine if treatment is consistent with one or more of the PQRI measures you've chosen to report

鈥� Assign the CPT and ICD-9 codes as you would normally for the claim.

鈥� Check to make sure your ICD-9 and CPT codes match the measure's requirements (see chart)

鈥� Assign the appropriate Category II or HCPCS code, and any modifiers that you need.

Even if your gastroenterologist doesn't perform a PQRI service, you should still report the appropriate code for an eligible case. You just append a PQRI modifier to explain why your doctor didn't perform the service:

鈥� 1P-- Performance measure exclusion modifier due to medical reasons

鈥� 2P-- Performance measure exclusion modifier due to patient reasons

鈥� 3P-- Performance measure exclusion modifier due to system reasons

鈥� 8P-- Performance measure reporting modifier -- action not performed, reason not otherwise specified.