PCPI, CPT and PQRI What the

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PCPI, CPT and PQRIWhat the

• Michael Beebe
• Director CPT
• April 17, 2007

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Overview

• AMAs Physician Consortium for Performance
  Improvement
• CPT? Category II Codes for Performance
  Measurement
• CMSs Physician Quality Reporting Initiative
• Tools to facilitate successful reporting under
  PQRI

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Current Environment

• The growing need
• Specialty-specific, physician-level clinical
  quality measures to be collected and reported for
  multiple purposes
• Internal QI
• Maintenance of certification
• Reimbursement (PQRI)
• The opportunity
• The medical profession is taking the lead in
  developing relevant measures for every specialty

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AMAs Physician Consortium for Performance
Improvement
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Physician Consortium for Performance Improvement

• Membership
• More than 70 national medical specialty and state
  medical society physician representatives
• Experts in methodology and data collection
• AHRQ, CMS
• Consultants
• NCQA/Joint Commission liaison
• Convened and staffed by AMA

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PCPI Objectives

• Measures for all physicians
• Measure for various implementation programs
  (medical boards, CME providers, private health
  plans, CMS)
• Current emphasis on CMS PQRI
• (59 of 74 PQRI measures PCPI/Specialty
  Society or PCPI/NCQA measures)

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PCPI Portfolio

• Total number of completed measurement sets 26
• Total number of completed individual measures
  155
• Total number of individual measures in
  development 52

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Measures in DevelopmentOngoing Work

• Perioperative Care I
• Chronic Kidney Disease (RPA)
• Atrial Fibrillation (ACC/AHA)
• Hepatitis C (AGA Institute)
• Acute Otitis Externa/Otitis Media with Effusion
  (AAO-HNS)
• Outpatient Parenteral Antimicrobial Therapy
  (IDSA)
• Anesthesiology (ASA)

• Prostate Cancer (AUA)
• Pathology (CAP)
• Oncology (ASCO/ASTRO)
• Degenerative Lumbar Spinal Stenosis (AANS/CNS,
  AAOS, AAPMR, NASS)
• Radiology (ACR)
• Dermatology (AAD)
• Eye Care (AAO)

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Measures in DevelopmentFuture Work - 2007

• Interventional Radiology (SIR)
• Nuclear Medicine (SNM)
• Sleep Medicine (AASM)
• Chronic Pain (ASA/AAPM)
• Substance Use (APA)
• Rhinosinusitis (AAAAI/AAO-HNS)
• HIV (IDSA)
• Thoracic Surgery (STS)
• Plastic Surgery Wound Care (ASPS)

• Rheumatoid Arthritis (ACRheum)
• AV Fistula (SVS)
• Neurology Multiple Sclerosis Epilepsy (AAN)
• Child and Adolescent Major Depressive Disorder
  (APA)
• Juvenile Idiopathic Arthritis (ACR)
• Hospitalists (SHM)
• Ophthalmology (AAO)
• Palliative Care (AAHPM)

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Measure MaintenanceTo be Reviewed in 2007

• Adult Diabetes
• Asthma
• Coronary Artery Disease
• Heart Failure
• Hypertension
• Preventive Care and Screening

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CPT Category II Codes for Performance Measurement

• Result of CPT-5 Project to make broad process and
  structural improvement in the CPT code set
• First introduced in 2003.

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CPT Category II Codes

• Facilitate data collection by coding certain
  services and/or test results that are agreed upon
  as contributing to positive health outcomes and
  quality patient care.
• Decrease the need for record abstraction and
  chart review, thus minimizing administrative
  burdens on physicians and data collection or
  survey costs for health plans.
• May be services that are typically included in an
  Evaluation and Management (E/M) service or other
  component parts of a service and are not
  appropriate for Category I CPT codes.

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Category II Codes Developed for the following
measure sets

• Asthma
• Chronic Obstructive Pulmonary Disease (COPD)
• Community Acquired Bacterial Pneumonia (CAP)
• Coronary Artery Bypass Graft (CABG)
• Coronary Artery Disease (CAD)
• Diabetes Adult (DM)
• Emergency Medicine (EM)
• End Stage Renal Disease (ESRD)
• Eye Care (EC)
• Gastroesophageal Reflux Disease (GERD)
• Geriatrics (GER)
• Heart Failure (HF)
• Hematology (HEM)

• Hypertension (HTN)
• Major Depressive Disorder (MDD)
• Melanoma (MEL)
• Osteoporosis (OP)
• Osteoarthritis (Adult) (OA)
• Pediatric Acute Gastroenteritis (PAG)
• Pediatric Pharyngitis
• Perioperative Care 2 (Peri 2)
• Prenatal-Postpartum Care (PRENATAL)
• Preventive Care and Screening Tobacco Use and
  Problem Drinking
• Stroke Stroke Rehab (STR)
• Upper Respiratory Infection (URI)

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Category II Release Cycle and Implementation
Period

• February CPT Editorial Panel February meeting
• March 15 release
• June 15 effective
• June CPT Editorial Panel meeting
• July 15 release
• October 15 effective
• October CPT Editorial Panel meeting
• Nov 15 release
• February 15 effective

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CPT Category II and PQRI Cycle

• CMS intends to issue updates to the PQRI in sync
  with the yearly updates to the Medicare Physician
  Fee Schedule
• CPT will need to consider a yearly update cycle

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Category II Structure

• Category II codes make use of an alphabetical
  character, F, as the 5th character in the
  string.
• Codes are arranged according to the following
  sections derived from standard clinical
  documentation format
• Composite Measures 0001F
• Patient Management 0500F-0503F
• Patient History 1000F-1002F
• Physical Examination 2000F
• Diagnostic/Screening Processes or Results 3000F
• Therapeutic, Preventive or Other Interventions
  5000F
• Follow-up, Patient Safety and Other Outcomes
  6000F
• Modifiers to indicate that a service specified by
  a performance measure was considered, but not
  performed
• Serve to exclude the patient from the denominator

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Category II, Appendix H

• Table that relates each CPT Category II code to a
  complete description of the performance measure,
  the developer of the measure or source and the
  developers internet site to access additional
  information on the measure.
• For each Category II code there is information on
  each measures numerator, denominator, and
  inclusion/exclusion criteria.
• Users are encouraged to review the complete
  measure(s) associated with each code prior to
  implementation of the Category II code.

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Clinical Topic/Condition Displays the specific
measure group that is being identified. All
Clinical Topics listed in Appendix H are in
alphabetic order.
Reporting Instructions Provides information
regarding how the codes listed within a measure
are intended to be used, including when to report
more than one code, when certain codes exclude
use of another code, when exclusionary modifiers
are appropriate.
Code number Listing. This colomn lists all CPT
codes that address compliance with the measure,
including Category I, II, and III codes.
Measure Title Displays the title of the
specific measure that is being examined. This
title is the same name that is used for the
measure within the measure developers web info.
Measure developer is referenced through footnotes
Numerator Statement Identifies the population
of patients for which the physician or health
professional met the measure requirements.
Denominator Statement Denotes the total
population for which the measure directives could
have been performed
Percentage Statement The calculation of
numerator and denominator notes the population
of patient and what is being measured.
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CPT Category II Modifiers

• 1P Performance Measure Exclusion Modifier due to
  Medical Reasons
• Includes
• not indicated (absence of organ/limb, already
  received/performed, other)
• contraindicated (patient allergic history,
  potential adverse drug interaction, other)
• 2P Performance Measure Exclusion Modifier due to
  Patient Reasons
• Includes
• patient declined,
• economic, social, or religious reasons,
• other patient reasons

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CPT Category II Modifiers

• 3P Performance Measure Exclusion Modifier due to
  System Reasons
• Includes
• Resources to perform the services not available
• Insurance coverage/payor-related limitations
• Other reasons attributable to health care
  delivery system
• 8P Performance measure reporting modifier -
  action not performed, reason not otherwise
  specified

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• 2007 Physician Quality Reporting Initiative (PQRI)

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Physician Quality Reporting Initiative (PQRI)

• Tax Relief and Healthcare Act (TRHCA) Section 101
  Implementation
• Eligible Professionals
• Quality Measures
• Form and Manner of Reporting
• Determination of Successful Reporting
• Bonus Payment
• Validation
• Appeals
• Confidential Feedback Reports
• 2008 Considerations
• Outreach and Education

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PQRI

• Eligible Professionals
• Medicare physician, as defined in Social Security
  Act (SSA) Section 1861(r)
• MD / DO
• DPM
• Doctor of Optometry
• Doctor of Oral Surgery
• Doctor of Dental Medicine
• Chiropractor

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PQRI

• Eligible Professionals
• Practitioners described in Social Security Act
  (SSA) Section 1842(b)(18)(C)
• Physician Assistant
• Nurse Practitioner
• Clinical Nurse Specialist
• Certified Registered Nurse Anesthetist
• Certified Nurse-Midwife
• Clinical Social Worker
• Clinical Psychologist
• Registered Dietitian
• Nutrition Professional

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PQRI

• Eligible Professionals
• Therapists
• Physical Therapist
• Occupational Therapist
• Qualified Speech-Language Pathologist
• All Medicare-enrolled eligible professionals may
  participate, regardless of whether they have
  signed a Medicare participation agreement to
  accept assignment on all claims

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PQRI Measures

• 66 2006 PVRP quality measures posted on
  December 5, 2006 adopted in statute
• 8 additional measures added, as allowed by
  statute
• Final list of 74 PQRI quality measures and
  detailed measure specifications posted at
  http//www.cms.hhs.gov/pqri/

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PQRI Form and Manner of Reporting

• Reporting period is July 1December 31, 2007
• Claims-based reporting
• CPT Category II codes (or temporary G-codes where
  CPT Category II codes are not yet available) for
  reporting quality data
• Quality codes may be reported on paper-based CMS
  1500 claims or electronic 837-P claims
• Quality codes, which supply the measure
  numerator, must be reported on the same claims as
  the payment codes, which supply the measure
  denominator
• No registration is required to participate

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PQRI - Determination of Successful Reporting

• Reporting thresholds
• If there are no more than 3 measures that apply,
  each measure must be reported for at least 80 of
  the cases in which a measure was reportable
• If 4 or more measures apply, at least 3 measures
  must be reported for at least 80 of the cases in
  which the measure was reportable
• Analysis is expected to be performed at the
  individual level
• Requires accurate and consistent use of
  individual National Provider Identifier (NPI) on
  claims

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PQRI Bonus Payment

• Participating eligible professionals who
  successfully report may earn a 1.5 bonus,
  subject to cap
• 1.5 bonus calculation based on total allowed
  charges during the reporting period for
  professional services billed under the Physician
  Fee Schedule
• Claims must reach the National Claims History
  (NCH) file by February 29, 2008
• Bonus payments will be made in a lump sum in
  mid-2008
• Bonus payments will be made to the holder of
  record of the Taxpayer Identification Number
  (TIN)
• No beneficiary co-payment or notice to the
  beneficiary

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PQRI Bonus Payment

• A payment cap that would reduce the potential
  bonus below 1.5 of allowed charges may apply in
  situations where an eligible professional reports
  relatively few instances of quality measure data.
  
• Eligible professionals caps are calculated by
  multiplying
• their total instances of reporting quality data
  for all measures (not limited only to measures
  meeting the 80 threshold) by
• a constant of 300 and by
• the national average per measure payment amount.
  

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PQRI Bonus Payment

• The national average per measure payment amount
  is one value for all measures and all
  participants that is calculated by dividing
• the total amount of allowed charges under the
  Physician Fee Schedule for all covered
  professional services furnished during the
  reporting period on claims for which quality
  measures were reported by all participants in the
  program by
• the total number of instances for which data were
  reported by all participants in the program for
  all measures during the reporting period.

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PQRI - Specifics

• Validation
• TRHCA requires CMS to use sampling or other means
  to validate whether quality measures applicable
  to the services have been reported
• Validation plan under development
• Appeals
• Determinations are excluded from formal
  administrative or judicial review
• CMS will establish an informal inquiry process

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PQRI Provider Feedback

• Confidential Feedback Reports
• 2007 PQRI quality data will not be publicly
  reported
• Reports will be available at or near the time of
  the bonus payments in 2008
• No interim reports
• Reports are expected to include reporting and
  performance rates

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PQRI - 2008 Considerations

• Measures must be established through rulemaking
• Proposed by August 15, 2007 finalized by
  November 15, 2007
• Statutory requirements for 2008 measures
• Adopted or endorsed by a consensus organization,
  such as the AQA Alliance or National Quality
  Forum (NQF)
• Include measures that have been submitted by a
  physician specialty
• Used a consensus-based process for development
• Include structural measures, such as the use of
  electronic health records or electronic
  prescribing technology

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PQRI - 2008 Considerations

• Registry-based and electronic record-based
  reporting
• Short lead time for implementation precludes
  using these channels for 2007 PQRI
• CMS is working toward opening these channels for
  2008 reporting
• Standardized specifications for centralized
  reporting could reduce the burden of reporting
  for participants and CMS

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PQRI - Outreach and Education

• Engagement through communication
• Website at https//www.cms.hhs.gov/PQRI
• Medicare Carrier/Medicare Administrative
  Contractor (MAC) inquiry management
• Speakers Bureau
• Education for participants and their office staff
• Working with AMA to develop tools to support
  successful reporting

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CPT and ICD codes for denominator, as required by
performance measure
PQRI Measure number and description
CPT II codes or exclusion modifiers for
numerator, as required by performance measure
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Physician and patient info
PQRI Measure number and description
Information to be completed by physician during
encounter
Information to be reported on claim
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