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Reimbursement Check

CMS Reporting Initiative Will Pay Physicians More

Berg, Elijah MD

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doi: 10.1097/01.EEM.0000296433.63511.70
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    The government wants to pay us more? Usually I would be the one to tell you not to believe the hype, but this time it's true! Due to a congressional mandate, Medicare will provide a bonus of up to 1.5 percent of all Medicare payments to physicians who participate in the Physician Quality Reporting Initiative (PQRI). Be aware, though: Medicare's proposed final rule released in July schedules physician payments to go down by 9.9 percent next year unless Congress intervenes, but that discussion is for another article.

    The Tax Relief and Health Care Act signed into law in December mandated that physicians be paid a 1.5 percent bonus for meeting certain quality measure reporting requirements for acute MI, chest pain, syncope, and pneumonia. The PQRI allows physicians to receive up to that 1.5 percent bonus only if they meet a threshold of reporting 80 percent of the time on at least three quality measures. For 2007 the program is designed to pay physicians for reporting on the measures, and payments do not depend on whether the specified clinical criteria are being met. The reporting period for the initial PQRI started with dates of service July 1 through Dec. 31, 2007, and the Centers for Medicare and Medicaid Services (CMS) stated that groups meeting the reporting requirements will be paid a one-time lump sum bonus during 2008.

    The CMS Vision

    CMS has big plans for this program, noting that its vision is “to build on Medicare's comprehensive efforts to substantially improve the health and function of our beneficiaries by preventing chronic disease complications, avoiding preventable hospitalizations, and improving the quality of care delivered.”

    CMS Administrator Mark McClellan, MD, PhD, testified before the House Ways and Means Subcommittee on Health: “CMS believes that an important component of delivering high quality health care is the ability to measure and evaluate quality. Accordingly, CMS is committed to the development of payment systems that will support and reward quality.”

    CMS has quickly rolled out the PQRI program, with real money at stake for emergency physicians. This is likely just the beginning of what will be growing CMS emphasis on quality processes with more measures being developed and likely an increasing portion of physician payments at stake. Ultimately, a Congressional fix to the physician fee schedule, which for next year is creating a looming 9.9 percent decrease, may be tied to adequate PQRI reporting.

    Quality Measures

    For 2007 reporting, 74 quality measures were developed by the Physician Consortium Performance Improvement Committee. Measures directly relevant to emergency medicine include aspirin at arrival for AMI, electrocardiogram performed for nontraumatic chest pain, electrocardiogram performed for syncope, vital signs for community-acquired bacterial pneumonia, assessment of oxygen saturation for pneumonia, assessment of mental status for pneumonia, empiric antibiotics for pneumonia, and beta-blockers for acute myocardial infarction.

    The ED discharge diagnosis that is submitted with the physician claim will drive the reporting process. CMS is using the discharge diagnosis to trigger the requirement for reporting quality measures. For example, patients assigned a diagnosis of acute MI generate a reporting requirement for providing aspirin.

    CMS and CPT have developed a series of special codes to report these new quality measures. The codes are part of the CPT Category 2 series and the Medicare G code series. As an example, if the physician documents that a patient with an acute MI received aspirin, the submitted claim should include code 4084F, which is a new CPT Category 2 code.

    Modifiers also describe extenuating circumstances when a measure's requirements are not fulfilled:

    • ▪ 1P: Performance measure exclusion modifier due to medical reasons; treatment contraindicated because of patient allergy, potential adverse drug interaction, or other reason.
    • ▪ 2P: Performance measure exclusion modifier due to patient reasons, such as the patient declining treatment.
    • ▪ 3P: Performance measure exclusion modifier due to system reasons, including resources such as equipment or supplies to perform the services not available.
    • ▪ 8P: Modifier available if a quality measure was not met, and there is no clear documentation.

    The following examples show how to report under the new system. For a 65-year-old man presenting with an acute MI, the physician documents giving aspirin and reports 4084F. For a 48-year-old woman presenting with an acute MI, the physician documents not giving aspirin due to a history of anaphylaxis and reports 4084F, 1P (medical reason). A 72-year-old man is brought in by EMS with an acute MI. No aspirin is given and nothing is documented (perhaps the aspirin was given by EMS, but the chart did not indicate it) and reports 4084F, 8P (reason not specified).

    Reporting

    To receive your 1.5 percent bonus payment, you must be reporting the ED PQRI measures. Physicians report on these measures using the newly developed CPT 2 codes and modifiers (1P, 2P, 3P, and 8P). These codes are submitted with the actual claim along with the other ED charges. The PQRI code goes on the actual claim form (or electronic equivalent), such as field 24 D of the CMS 1500.

    Physicians will be scored individually at the National Provider Identifier (NPI) level. Physicians achieving greater than 80 percent reporting of the quality codes on three or more measures will be awarded a PQRI bonus. Ultimately, payment of the PQRI bonus will be made to the Tax ID number or Employer Identification Number (EIN) of the group.

    Physician voluntary reporting may well be the first step toward increasingly significant amounts of revenue being at stake based on quality measures. Many congressional leaders have a vision of paying physicians for quantity and quality. Although the clinical relevance of certain quality measurements is still being debated, they are a reality that must be fully understood to achieve full reimbursement for the care you are providing.

    CMS REPORTING MODIFIERS FOR PHYSICIAN BONUS PAYMENT

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    • ▪ 1P: Performance measure exclusion modifier due to medical reasons; treatment contraindicated because of patient allergy, potential adverse drug interaction, or other reason.
    • ▪ 2P: Performance measure exclusion modifier due to patient reasons, such as the patient declining treatment.
    • ▪ 3P: Performance measure exclusion modifier due to system reasons, including resources such as equipment or supplies to perform the services not available.
    • ▪ 8P: Modifier available if a quality measure was not met, and there is no clear documentation.

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