The quality movement, a driving force in how hospitals manage and measure patient care, will soon reach clinicians’ offices nationwide. On July 1, the Centers for Medicare & Medicaid Services (CMS) will launch a new Physician Quality Reporting Initiative (PQRI). A variety of healthcare providers who see Medicare patients can participate in the voluntary program—and earn a bonus on their Medicare reimbursement.
Providers from 19 different categories can participate, including doctors, nurses, social workers, psychologists, dieticians, and physical and occupational therapists. CMS has established specifications for 74 quality measures eligible for reporting under the six-month program. Six of the measures are relevant to treatment of adult rheumatology patients—five pertain to osteoporosis and one to falls. (See “PQRI Rheumatology Quality Measures,” below.)
Physicians interested in participating simply need to report these quality measures to Medicare on their reimbursement claims (paper form CMS 1500 or electronically) using the appropriate Current Procedural Terminology (CPT) Category II codes or G-codes. Reimbursement for the codes should be listed as $0.00, as this field cannot be left blank. The codes will appear to be denied, but the quality-data codes reported will be accepted into the system, analyzed, and considered in bonus payment eligibility calculations. The 2007 reporting period is July 1 through December 31. The incentive for reporting is a 1.5% bonus on total allowed charges submitted for professional services under the Medicare Fee Schedule. “Our goal is to transform Medicare from being a passive payer to an active purchaser,” says Thomas Valuck, MD, director of the special program office for value-based purchasing at CMS.
“It is important to realize that this is just the first step in a CMS program that is moving toward quality-based reimbursement,” says Larry Anderson, MD, director of quality improvement for MaineHealth, Maine Medical Center Physician Hospital Organization in Portland and a member of the ACR’s Quality Measures Committee. “You get paid for reporting [alone], but that will migrate to paying for results and performance. While the bonus of 1.5% may not be enough to entice people to [participate], it’s an opportunity for practices to gain experience reporting these kinds of performance measures because it’s going to be commonplace in years to come.”
Participating now will help providers improve their processes and to compare themselves with providers nationwide through confidential feedback reports. In the future, “the amount of money at stake might increase,” says Dr. Valuck, and it might be based on outcomes, with congressional approval. Additionally, the results might become public. “This is an opportunity to [prepare] for a more intensive pay-for-performance program,” he says.
“While the bonus of 1.5% may not be enough to entice people to [participate], it’s an opportunity for practices to gain experience reporting these kinds of performance measures, because it’s going to be commonplace in years to come.”
Bonus Nuts and Bolts
In this first step, providers will not be required to report outcomes, but rather only whether they performed an action reflected in the measure. Providers will be asked to report if a patient has had a certain procedure based on the eligible quality measures. For example, if a female patient age 65 or older had a DXA ordered or performed at least once since age 50 or medication prescribed within 12 months. You have to document this in your record in case of audit.
To qualify for the bonus, you must report each measure for at least 80% of the patient visits that qualify based on the patient’s diagnoses and the type of visit. Further, you need only report on three measures at the 80% level to qualify for the bonus. For example, you would qualify for a bonus if you performed and reported measures 39 (Osteoporosis: Screening or Therapy for Women 65 and Older), 41 (Osteoporosis: Pharmacologic Therapy), and 42 (Osteoporosis: Counseling for Vitamin D, Calcium Intake, and Exercise) during 80% of your office visits with patients diagnosed with osteoporosis.
In order to successfully integrate PQRI into their practices, “Professionals need to confirm that the software they are currently using to submit claims will accept the quality data CPT-II codes,” says says Susan Nedza, MD, co-lead for education and outreach for PQRI, and chief medical officer for CMS Region V. “The change in the practice is related to capturing the measurement activity in the chart and transferring to the claims process. We recommend using flow sheets, templates, or—if they have an electronic medical record—having data fields where they can record the quality data codes for submission throughout the claims process. CMS will soon have tools available to facilitate capture that will be posted on the PQRI Web site.”
David Holzman is a freelance writer based in Massachusetts.
PQRI Rheumatology Quality Measures
To qualify for a bonus in 2007, rheumatologists and health professionals must report each measure for at least 80% of the relevant cases seen between July 1 and December 31, and they must meet that goal on at least three of these measures if four or more are applicable.
#4: Screening for Future Fall Risk: Percentage of patients 65 or older who were screened for future fall risk (patients are considered at risk for future falls if they have had two or more falls in the past year or any fall with injury in the past year) at least once within 12 months.
#24. Osteoporosis: Communication with the Physician Managing Ongoing Care Post Fracture: Percentage of patients 50 or older treated for a hip, spine, or distal radial fracture with documentation of communication with the physician managing the patient’s ongoing care that a fracture occurred and that the patient was or should be tested or treated for osteoporosis.
#39. Osteoporosis Screening or Therapy for Women 65 and Older: Percentage of female patients 65 or older who have a central dual-energy X-ray absorptiometry (DXA) measurement ordered or performed at least once since age 60 or pharmacologic therapy prescribed within 12 months.
#40. Osteoporosis: Management Following Fracture: Percentage of patients 50 or older with fracture of the hip, spine, or distal radius who had a central dual-energy X-ray absorptiometry (DXA) measurement ordered or performed or pharmacologic therapy prescribed.
#41. Osteoporosis: Pharmacologic Therapy: Percentage of patients 50 or older with a diagnosis of osteoporosis who were prescribed pharmacologic therapy within 12 months.
#42. Osteoporosis: Counseling for Vitamin D, Calcium Intake, and Exercise: Percentage of patients, regardless of age, with a diagnosis of osteoporosis who are either receiving both calcium and vitamin D or have been counseled regarding both calcium and vitamin D intake and exercise at least once within 12 months.