Medicare 2007 PQRI Quality Measures

1. Centers for Medicare & Medicaid Services
2007 Physician Quality
Reporting Initiative (PQRI)
Coding for Quality:
The Measures
Module IV
June 13, 2007
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2. Disclaimers
This presentation was current at the time it was published or uploaded onto the
web. Medicare policy changes frequently so links to the source documents
have been provided within the document for your reference.
This presentation was prepared as a tool to assist providers and is not intended
to grant rights or impose obligations. Although every reasonable effort has
been made to assure the accuracy of the information within these pages,
the ultimate responsibility for the correct submission of claims and response
to any remittance advice lies with the provider of services. The Centers for
Medicare & Medicaid Services (CMS) employees, agents, and staff make
no representation, warranty, or guarantee that this compilation of Medicare
information is error-free and will bear no responsibility or liability for the
results or consequences of the use of this guide. This publication is a
general summary that explains certain aspects of the Medicare Program,
but is not a legal document. The official Medicare Program provisions are
contained in the relevant laws, regulations, and rulings.
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3. Disclaimers
The Medicare Learning Network (MLN) is the brand name for official CMS
educational products and information for Medicare fee-for-service providers.
For additional information visit the Medicare Learning Network’s web page
at www.cms.hhs.gov/MLNGenInfo on the CMS website.
Current Procedural Terminology (CPT) is copyright 2006 American Medical
Association. All Rights Reserved. No fee schedules, basic units, relative
values, or related listings are included in CPT. The AMA assumes no liability
for the data contained herein. Applicable FARS/DFARS restrictions apply to
government use.
The International Classification of Diseases, 9th Revision, Clinical Modification
(ICD-9-CM) is published by the United States Government. A CD-ROM,
which may be purchased through the Government Printing Office, is the
only official Federal government version of the ICD-9-CM. ICD-9-CM is an
official Health Insurance Portability and Accountability Act standard.
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4. Overview
• PQRI Introduction: Information about PQRI
• PQRI Tools: Implementing PQRI
• PQRI Principles: Understanding the
Measures
• PQRI Coding: Examples of Measures
• PQRI Readiness: Ensuring Success
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5. PQRI Introduction:
Value-Based Purchasing
• Value-based purchasing is a key
mechanism for transforming Medicare from
a passive payer to an active purchaser.
– Current Medicare Physician Fee Schedule is
based on quantity and resources consumed,
NOT quality or value of services.
• Value = Quality / Cost
– Incentives can encourage higher quality and
avoidance of unnecessary costs to enhance the
value of care.
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6. PQRI Introduction:
Focus on Quality
• PQRI reporting will focus attention on
quality of care.
– Foundation is evidence-based measures
developed by professionals
– Measurement enables improvements in care
– Reporting is the first step toward pay for
performance
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7. PRQI Introduction:
The Process
Visit Documented in Encounter Form Coding & Billing
the Medical Record
NCH
Analysis Contractor National Claims Carrier/MAC
History File
Confidential Bonus Payment
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Report Procurement Sensitive
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8. PQRI Introduction:
Feedback Reports
• Confidential Feedback Reports
– enable quality improvement at the
practice level
– include reporting and performance
rates by NPI for each TIN.
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9. PQRI Introduction:
Key Information
• Reporting period: Dates of Service
between July 1, 2007 through December
31, 2007
• No need to register: just begin reporting
• Must be an enrolled Medicare provider (but
need not have signed a Medicare
participation agreement)
• Need to use individual National Provider
Identifier (NPI).
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10. Coding for Quality:
PQRI Tools
Implementing
PQRI
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11. PQRI Tools:
Where to Begin
• Gather information and educational
materials from the PQRI web page:
www.cms.hhs.gov/pqri on the CMS
website.
• Gather information from other sources,
such as your professional association,
specialty society or the American Medical
Association.
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12. PQRI Tools:
The PQRI Website
• www.cms.hhs.gov/pqri
– Overview
– CMS Sponsored Calls
– Statute/Regulations/Program Instructions
– Eligible Professionals
– Measures/Codes
– Reporting
– Analysis and Payment
– Educational Resources
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13. PQRI Tools:
The Measure List
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Procurement Sensitive
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14. PQRI Tools: MLN 5640: Coding and
Reporting Principles
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Procurement Sensitive
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15. PQRI Tools: Coding for Quality
A Handbook for PQRI Participation
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Procurement Sensitive
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16. PQRI Tools: Coding for Quality
A Handbook for PQRI Participation
• Selecting measures and preparing to report
• PQRI coding and reporting principles for the
claims based submission of quality data codes
• Sample clinical scenarios for each measure, listed
by clinical condition/topic, describes successful
reporting (and performance where applicable)
• PQRI Glossary
• 2007 PQRI Code Master
• Sample implementation flow chart
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17. PQRI Tools: Coding for Quality
A Handbook for PQRI Participation
Examples of Clinical Conditions/Topics
• Clinical Conditions • Clinical Topics
– Asthma – Advance Care Planning
– Cancer ( Breast, Colon, – Screening for Fall Risk
CLL, etc) – Imaging
– Chest Pain – Medication
– COPD Reconciliation
– CAD – Perioperative Care
– Depression
– Diabetes
– GERD
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18. PQRI Tools: Measure- specific Data
Collection Worksheets
• Measure Specific
– Measure Description
– Worksheet
– Coding Specifications
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19. PQRI Tools:
The Code Master
• Excel Spreadsheet
– a sequential list of all ICD-9-CM (I9)
– CPT ® (CPT4) codes (including CPT II Codes)
– CPT II exclusion modifiers that are included in
the 2007 PQRI.
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20. Coding for Quality:
PQRI Principles
Understanding the Measures
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21. Understanding the Measures:
Commonalities
• 74 unique measures associated with
clinical conditions that are routinely
represented on Medicare Fee-for-Service
(FFS) claims
– ICD-9-CM diagnosis codes
– HCPCS codes
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22. Understanding the Measures:
Scope
• The measures address various aspects of
quality care
– Prevention
– Chronic Care Management
– Acute Episode of Care Management
– Procedural Related Care
– Resource Utilization
– Care Coordination
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23. Understanding the Measures:
Construct
Clinical action required for reporting and
performance
________________________________
Eligible cases for a measure (the eligible
patient population associated with the
numerator)
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24. Understanding the Measures:
Construct
CPT II Code
or
Temporary G Code
________________________________
ICD-9-CM
and
CPT Category I Codes
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25. Understanding the Measures:
Quality Data Codes
Quality-Data Codes translate clinical actions
so they can be captured in the
administrative claims process
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26. Understanding the Measures:
Quality Data Codes
• Quality-Data Codes can relay that:
– The measure requirement was met
or
– The measure requirement was not met due to
documented allowable performance exclusions
(i.e., using performance exclusion modifiers)
or
– The measure requirement was not met and the
reason is not documented in the medical record
(i.e., using the 8P reporting modifier)
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27. Understanding the Measures:
The Performance Modifiers
• Performance Measure Exclusion Modifiers indicate that an
action specified in the measure was not provided due to
medical, patient or systems reason(s) documented in the
medical record:
– 1P- Performance Measure Exclusion Modifier due to Medical Reasons
– 2P- Performance Measure Exclusion Modifier used due to Patient
Reason
– 3P- Performance Measure Exclusion Modifier used due to System
Reason
• One or more exclusions may be applicable for a given
measure. Certain measures have no applicable exclusion
modifiers. Refer to the measure specifications to determine
the appropriate exclusion modifiers.
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28. Understanding the Measures:
The Reporting Modifier
• Performance Measure Reporting Modifier
facilitates reporting a case when the patient
is eligible but the action described in a
measure is not performed and the reason
is not specified or documented
– 8P- Performance Measure Reporting
Modifier- action not performed, reason
not otherwise specified
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29. Understanding the Measures:
Performance Time Frame
• Some measures have a Performance
Timeframe related to the clinical action
that may be distinct form the reporting
frequency.
– Perform within 12 months
– Most Recent
• Clinical test result needs to be obtained,
reviewed, reported one time. It need not
have been performed during the reporting
period.
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30. Understanding the Measures:
Reporting Frequency
• Each measure has a Reporting Frequency
requirement for each eligible patient seen
during the reporting period
– Report one-time only
– Report once for each procedure performed
– Report for each acute episode
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31. Coding for Quality:
PQRI Coding
Examples
Of
Measures
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32. Coding for Quality
• NOTE: The following are examples of draft
worksheets that will be made available soon to
facilitate PQRI data capture and reporting.
• In some cases, the material upon which they are
based has changed. Final data worksheets and
supporting documents will be available on the
CMS PQRI website in advance of July 1, 2007.
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33. Coding for Quality:
Example #1- Prevention
Measure #4 – Screening for
Future Fall Risk
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Procurement Sensitive
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35. 35
Procurement Sensitive
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Current Procedural Terminology © 2006 American Medical Association. All Rights Reserved.

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Procurement Sensitive
Current Procedural Terminology © 2006 American Medical Association. All Rights Reserved. 36

37. Coding for Quality:
Example #2-Chronic Care Management
Measure #5 – Angiotensin
Converting Enzyme (ACE)
Inhibitor or Angiotensin
Receptor Blocker (ARB)
Therapy for Left Ventricular
Systolic Dysfunction (LVSD)
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Procurement Sensitive
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38. 38
Procurement Sensitive
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39. Tool: Worksheet
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Procurement Sensitive
Current Procedural Terminology © 2006 American Medical Association. All Rights
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Reserved.

40. Current Procedural Terminology © 2006
American Medical Association. All Rights
Reserved.
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Procurement Sensitive
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41. Coding for Quality:
Example #3- Acute Episode of Care Management
Measure #55 –
Electrocardiogram (ECG)
Performed for Syncope
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Procurement Sensitive
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42. 42
Procurement Sensitive
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43. 43
Procurement Sensitive
Current Procedural Terminology © 2006 American Medical Association. All Rights
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Reserved.

44. Current Procedural Terminology © 2006 American Medical Association. All Rights Reserved.
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Procurement Sensitive
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45. Coding for Quality:
Example #4- Procedural Related Care
Measure # 20 – Timing of
Antibiotic Prophylaxis –
Ordering Physician
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Procurement Sensitive
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46. 46
Procurement Sensitive
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47. 47
Current Procedural Terminology © 2006 American Medical
Procurement Sensitive
Association. All Rights Reserved. 47

48. 48
Procurement Sensitive
Current Procedural Terminology © 2006 American Medical Association. All
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Rights Reserved.

49. Current Procedural Terminology © 2006 American
Medical Association. All Rights Reserved.
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Procurement Sensitive
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50. Coding for Quality:
Example #5-Resource Utilization
Measure #66 – Appropriate
Testing for Children with
Pharyngitis
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Procurement Sensitive
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Procurement Sensitive
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52. 52
Procurement Sensitive
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Current Procedural Terminology © 2006 American Medical Association. All Rights Reserved.

53. Current Procedural Terminology © 2006 American
Medical Association. All Rights Reserved.
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Procurement Sensitive
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54. Coding for Quality:
Example #6- Care Coordination
Measure # 47– Advance Care
Plan
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Procurement Sensitive
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55. 55
Procurement Sensitive
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56. 56
Procurement Sensitive
Current Procedural Terminology © 2006 American Medical Association. All
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Rights Reserved.

57. Current Procedural Terminology © 2006 American
Medical Association. All Rights Reserved.
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Procurement Sensitive
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58. Coding for Quality:
PQRI Readiness
Ensuring
Success
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59. PQRI Reporting:
Ensuring Success
• Eligible professionals interested in testing their billing
system and practice readiness prior to July 1 will have an
opportunity to do so.
• CMS has designated code G8300 as a test code for PQRI
reporting for dates of service prior to July 1, 2007. Note
that G8300 will become 'Not Valid for Medicare Purposes’
effective for dates of service on and after July 1, 2007.
Providers should not submit this code on claims for dates
of service on and after July 1.
• Simply add the G8300 as a line item on any claims for
services prior to July 1, 2007.
• Enter “$0.00” or “$0.01” as the line item charge for the
test code. This will test the ability of the billing software or
clearance house to accept either.
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Current Procedural Terminology © 2006 American Medical Association. All Rights Reserved.

60. PQRI Reporting:
Ensuring Success
• Start reporting early to increase the probability of
achieving the 80 percent rate of reporting during
the reporting period.
• Report on as many measures as possible to
increase the likelihood of achieving successful
reporting.
• Report on as many eligible patients as you can to
decrease the probability of being subject to the
bonus cap.
• Ensure that quality codes are reported on the
same claim as the diagnosis or CPT-I codes.
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Current Procedural Terminology © 2006 American Medical Association. All Rights Reserved.

61. PQRI Reporting:
Ensuring Success
• Educational Resources
– CMS PQRI website contains all publicly available
information at: www.cms.hhs.gov/PQRI
• Frequently Asked Questions
• PQRI Fact Sheet
• Medicare Carrier/Medicare Administrative Contractor (MAC)
inquiry management
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