AAN Audio Conference: Medicare Physician Quality Reporting Initiative PQRI

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AAN Audio ConferenceMedicare Physician Quality
Reporting Initiative (PQRI)

• Are YOU Ready?
• James C. Stevens MD,FAAN
• Chair AAN Practice Committee
• Chair P4P Workgroup
• June 19, 2007
• Disclosures None

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Medicare Physician Quality Reporting Initiative
(PQRI)

• Why Should I Care?

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Times are changing

• PQRI
• Authorized by Congress (December, 2006)
• Based on Institute of Medicine reports
• Pay-for-reporting program
• Voluntary
• Potential 1.5 bonus for successful reporting
• Effective July 1 December 31, 2007
• Applies to Medicare Part B (Fee for Service)

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PQRI Goals

• First step in moving Medicare to an active
  purchaser of high quality, efficient care
• Participants begin to focus on quality of care by
  reporting
• Uses consensus and evidence-based quality
  measures
• Reported data will lead to improvements in care
• Lays foundation for a full pay-for-performance
  program in Medicare

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PQRI Participation Checklist

• NPI National Provider Identification
• TIN Tax Identification Number
• Review PQRI Measure Set
• Identify eligible patients for selected quality
  measures
• Reporting Period (July 1 Dec 31, 2007)
• Bonus paid to holder of TIN in mid-2008
• No registration needed, just start reporting

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74 PQRI Measures

• Neurology-specific
• Inpatient Stroke Care
• Admission measures (3)
• Discharge measures (3)
• Neuroimaging in Stroke/Rehabilitation (2)
• General
• Screening for Future Fall Risk (1)
• Advance Care Plan (1)
• Medication Reconciliation (1)

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Inpatient Stroke Measures

• ADMISSION MEASURES
• DVT prophylaxis in patients with ischemic stroke
  or intracranial hemorrhage by end of hospital day
  two
• 2. Tissue Plasminogen Activator (t-PA)
  considered for pts with ischemic stroke whose
  time from symptom onset to arrival lt 3 hours
• 3. A dysphagia screening process before taking
  any foods, fluids or medications by mouth in
  patients with ischemic stroke or ICH

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Inpatient Stroke Measures

• DISCHARGE MEASURES
• Antiplatelet therapy prescribed at discharge in
  patients with ischemic stroke or TIA
• Anticoagulant prescribed at discharge in patient
  with ischemic stroke or TIA with documented
  permanent, persistent, or paroxysmal atrial
  fibrillation
• Consideration for rehabilitation services is
  documented in patients with ischemic stroke or ICH

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Neuroimaging Stroke Measures

• CT or MRI performed within 24 hours of arrival to
  hospital in patients with ischemic stroke, TIA or
  ICH to document the presence or absence of
  hemorrhage, mass lesion acute infarction
• Carotid Imaging reports (neck MRA, Neck CTA, neck
  duplex ultrasound, carotid angiogram) in patients
  with ischemic stroke or TIA that include direct
  or indirect reference to measurements of distal
  internal carotid diameter as the denominator for
  stenosis measurement

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Other Measures

• Screening for future fall risk (inquire to
  occurrence of 2 or more falls OR any fall with
  injury over the past year) in ANY patient 65
  years of age and older
• Medication reconciliation of discharge
  medications with current medication list in ANY
  patient 65 years of age and older discharged from
  an inpatient facility in last 60 days
• Documentation of a surrogate decision-maker or
  advance care plan in medical record in ANY
  patient 65 years of age and older

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Quality Measure Specifications

• All 74 PQRI Quality Measures have
• Denominator ICD-9 and/or E/M codes identify
  pts/visits that a measure is applicable
• Numerator CPT II codes translate the clinical
  actions related to each reported measure
• Modifiers explain rationale behind the clinical
  action being reported

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Modifiers

• Performance Measure Exclusion Modifiers indicate
  why action specified by the quality measure was
  not done because of
• 1P Medical Reasons
• 2P Patient Reason
• 3P System Reason
• 8P Reason not specified
• Not all modifiers apply to each measure

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How to Report

• Patients or visits eligible for reporting are
  determined by ICD-9 and/or E/M code listed on
  claims form (denominator)
• Clinical action related to measure is performed
  and noted on claims worksheet
• Billing staff includes CPT II code (numerator
  modifier) with the service codes on claims form
  (837 electronic or paper 1500 form)
• CPT II codes line items will be denied for
  payment, but routed to NCH file for analysis

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1500 Form Stroke Reporting
Denominator
433.01
427.31
1 68.22
99221 (initial inpatient)
04 21 07 04 21 07 21
04 23 07 04 23 07 21 99239
(hosp d/c day mgmt) 1 100.81

04 23 07 04 23 07 21 4073F
(antiplatelet at d/c) 1
0.00
04 23 07 04 23 07 21 4075F
1P(antiocoag, med reas) 1,2 0.00
04 23 07 04 23 07 21 4079F
(rehab consid) 1
0.00
CPT CPT II codes for mult. measures
Diagnosis Indicator
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Successful Reporting

• If 4 or more measures are applicable, you must
  report on at least 3 for 80 of eligible patients
  or visits
• each of the 3 measures must be reported 80 of
  the time
• If fewer than 3 measures apply, you must
  correctly report on 80 of eligible patients or
  visits
• Reporting 1-2 measures will trigger validation
  process

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Reporting Example DVT for Stroke or ICH

Dr. Jones admits Mrs. White to the hospital (CPT
99222) after an ischemic stroke (ICD-9 433.21)
SCENARIO I Dr. Jones orders DVT prophylaxis for
Mrs.White. The patient receives DVT
prophylaxisby end of hospital daytwo. Dr. Jones
documents order in chart and reports CPT II
code 4070F
SCENARIO II Mrs. White is independently
ambulatory after her stroke,so Dr. Jones does
not order DVT prophylaxis. Dr. Jones documents
the reason and reports CPT II code 4070F (1P)
SCENARIO III There is no documentation that Dr.
Jones ordered DVTprophylaxis and no reason is
specified. He reports CPT II 4070F (8P)
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Reporting Example Advance Care Plan

Office visit Dr. Jones sees Mrs. White
Chart is flagged because pt. is 70 yrs old
SCENARIO I Dr. Jones asks Mr. Smith If he has an
advanced care plan or surrogate decision maker.
He does. Dr. Jones documents care plan in chart
and reports CPT II code 1080F
SCENARIO II Dr. Jones asks Mr. Smith about his
advance care plans, but Mr. Smith does not wish
to discuss them. Dr. Jones documents discussion
and reports CPT II code 1080F (2P)
SCENARIO III There is no documentation that Dr.
Jones discussed a surrogate or advanced care plan
with Mr. Smith and no reason is specified. He
reports CPT II 1080F (8P)
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Reporting Example Fall Risk Screening
Office visit Dr. Jones sees Mr. Smith

Chart is flagged because pt. is 70 yrs old
Dr. Jones asks Mr. Smith if he has fallen in the
last year
Mr. Smith has had 2 or more falls (or 1 with
injury), Dr. Jones documents reports CPT II
code 1100F
Mr. Smith has not had any falls (or only 1 fall
without injury). Dr. Jones documents
reports CPT II code 1101F
There is no documentation that Dr. Jones
discussed Mr. Smiths fall history and no
reason is specified. He reports CPT II 1000F
(8P)
Mr. Smith is not ambulatory. Dr. Jones documents
reports CPT II code 1101F (1P)
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Bonus Payment

• Successful PQRI participants are eligible for
  1.5 bonus payment on ALL Medicare claims
  submitted (July 1-Dec. 31, 2007)
• Bonus may be capped if individual instances of
  reporting are infrequent
• Participants reporting on lt3 measures are more
  likely to be subject to cap calculation
• Bonus paid to holder of TIN mid-2008 analysis
  feedback occurs at NPI level

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Practice Modifications

• To implement PQRI reporting
• Use CMS or AAN worksheets to simplify reporting
  claims process
• Modify billing sheets
• Make sure electronic medical records accept CPT
  II codes
• Modify billing system to accept 0.00 or 0.01
  charges for quality code line items
• Educate all affected office members

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WHY SHOULD I ?

• THE POSITIVES
• Opportunity to affect the process with feedback
• Outcomes improved by implementation of
  evidence-based measures
• AAN members participated in development of
  measures to ensure validity/meaning/ability to
  implement in neurology-based practice
• Get your practice ready for the inevitable

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WHY SHOULD I ?

• THE POSITIVES
• Can participate whether you have EHR/Electronic
  transmission capabilities or not
• Extra pocket change
• Future venue for meeting MOC-4 requirements

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WHY SHOULD I ?

• THE NEGATIVES
• ONE MORE THING (hassle factor)
• Ploy to cut my reimbursement
• Reflects only tiny segment of clinical practice
• Incentive not enough
• Does this really affect outcomes?

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How Can I Decide?

• Look at Medicare allowed charges for July 1 to
  Dec. 31, 2006 and multiply by 1.5
• Look at your patient population and decide if the
  available quality measures apply
• Look inward to decide if you want to have input
  in shaping a process that may NOT be voluntary in
  the future

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Health Care is YOUR Business!

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AAN Support

• Preparing members for PQRI participation
• Online tools (www.aan.com/p4p)
• Worksheets to help reporting workflow
• FAQs
• PQRI listserv to discuss challenges with other
  AAN members
• Measure specifications
• Webcasts of P4P programs at Annual Meeting

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Other AAN Activities

• AAN working with commercial payers to
• accept CPT II Codes
• standardize reporting requirements
• reduce administrative burden on practice
• AAN working to influence CMS quality
  improvement/payment program by
• increasing the number of measures for
  neurologists
• expanding opportunities for clinical data
  exchange through EMR, NCDR -CARE Registry, and
  other registries

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QUESTIONS?Email p4p_at_aan.com