November 11, 2007

Schnucks Free Antibiotic Program Added To GenericMedList

Schnucks stores announced a free generic antibiotic program on 10/28/2007. Schnucks pharmacies will provide a free 21 day supply of select antibiotics with a prescription.

The list of generic antibiotics included in the Schnucks program can be found at GenericMedList.com


More Information
Article in St Louis Post-Dispatch
Official Schnucks Program Website


October 24, 2007

Kroger $4 Drug list added to GenericMedList

Kroger stores announced generic medication discount program October 12, 2007 at select Kroger stores. Kroger now prices selected generic drugs at $4 for a 30 day supply.

The list of generic drugs included in the Kroger program can be found at GenericMedList


October 1, 2007

New Pulmonary Artery Hypertension MedicalTemplate

A new pulmonary artery hypertension MedicalTemplate was released 10/1/07.

The pulmonary artery hypertension evaluation MedicalTemplate is suitable for any health care provider that manages patients with known or suspected pulmonary artery hypertension in inpatient and ambulatory settings.


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Read this document on Scribd: Pulmonary Arterial Hypertension Evaluation

Pulmonary Arterial Hypertension Evaluation Date Start time Stop time Allergies History of present illness ‰Fatigue, weakness ‰Cough ‰Pain ‰Decreased appetite ‰Hemoptysis ‰Weight loss ‰Calcinosis ‰Raynaud’s ‰Esophageal dysfunction ‰Sclerodactyly ‰Telangiectasias ‰Dyspnea ‰Asymptomatic with usual activity ‰Symptomatic with usual activity ‰Symptomatic with minimal activity ‰Symptomatic at rest Chief complaint/Reason for consult MRN ‰Allergy list reviewed ‰ No drug allergies ‰ No food allergies Medications ‰Medication list reviewed ‰Med list reconciled with Nursing Home, Skilled Nursing facility or Rehab facility med list œ46 Social History ‰ Tobacco use ____ Packs x ____ Yrs ‰Chronic exposure to second hand smoke Daily, occasional and ex-smokers are more likely to be hazardous drinkers Review of Systems See HPI WNL ‰ Quit ‰ Alcohol use ______ Drinks per ‰ day ‰ week Hazardous drinking NIAAA (National Institute on Alcoholism and Alcohol Abuse guidelines) Men > 14 drinks per week OR > 4 drinks per day Women > 7 drinks per week OR >3 drinks per day ‰ Recreational drug use ‰Inhalational ‰Injectable ‰Ingestible ‰ Drug dependence ‰Narcotics ‰Benzodiazepines Constitutional Eyes ENT/mouth Resp CV GI GU Musc Skin/breasts Neuro Endo Heme/lymph Allergy/Immun Psych Occupational History ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ Fatigue, malaise, change in appetite Vision changes, new pain, scotomas Nose bleeds, dental Caries, dental abscesses, jaw pain Phlegm, wheeze, witnessed apnea, excessive daytime sleepiness Chest pain, diaphoresis, ankle edema, PND, syncope Emesis, dysphagia, GERD, abdominal pain, diarrhea, melena Change in urinary habits, hematuria, dysuria Myalgias, recent trauma, bony fractures, arthralgias, joint swelling or redness Rashes, new masses or skin lesions, increased sensitivity to sun exposure Headache, Paresthesias, Muscle weakness, difficulty with speech, seizures, tremor Hair loss, polydipsia, polyuria, gynecomastia Bleeding gums, unusual bruising, swollen lymph nodes Sinus probs, recurrent infections, anaphylaxis Mood changes, agitation, psychosis, delirium, dementia Family Medical History ‰ AV Malformations ‰ Pulmonary Hypertension ‰ Rheumatoid Arthritis ‰ Scleroderma ‰ Systemic Lupus Erythematosus ‰ Malignancy ‰ Breast ‰ Colon ‰ Lung ‰ Melanoma ‰ Prostate ‰ Renal cell ‰ Testicular ‰ Thyroid ‰ Other Past Medical and Surgical History ‰ Asthma ‰ Appetite Suppressant Use ‰ Neuromuscular weakness ‰ Bronchiectasis ‰ AV Malformations ‰ Occupational exposures ‰ Cryptogenic Organizing Pneumonia (BOOP) ‰ Cerebral Artery Disease ‰ Peripheral Artery Disease ‰ COPD ‰ Congenital Heart Defects ‰ Scleroderma ‰ Cystic Fibrosis ‰ Left to Right Shunt ‰ Seizure Disorder ‰ Histiocytosis ‰ Atrial Septal Defect ‰ Sjogren ‰ Obstructive Sleep Apnea ‰ Ventricular Septal Defect ‰ Systemic Lupus Erythematosus ‰ CPAP ‰ BiPAP ‰ Patent Ductus Arteriosus ‰ Renal Dysfunction ‰ Tuberculosis ‰ Congestive Heart Failure ‰ Rheumatoid Arthritis ‰ Pulmonary Arterial Hypertension ‰ Coronary Artery Disease ‰ Thrombotic Disease ‰ Pulmonary fibrosis ‰ Dermatomyositis/Polymyositis ‰ Thyroid Disease ‰ Pulmonary Thromboembolic Disease ‰ Diabetes ‰ Malignancy ‰ Pulmonary Venoocclusive Disease ‰ Diastolic Dysfunction ‰ Breast ‰ Sarcoidosis ‰ Nocturnal GERD ‰ Colon ‰ Tuberculosis ‰ Hepatic Dysfunction ‰ Lung Surgeries ‰ HIV/AIDS ‰ Melanoma ‰ Hypertension ‰ Prostate ‰ Inflammatory Bowel Disease ‰ Renal cell ‰ Mitral Stenosis or Regurgitation ‰ Testicular ‰ Mixed Connective Tissue Disorder ‰ Thyroid ‰ Myocarditis/Pericarditis ‰ Other ©MB and RR 2006, 2007 Revised 26Sep07 Pulmonary Arterial Hypertension Evaluation Vitals Weight BMI Temperature BP Pulse Sats At Rest With Activity CVP Cardiac Output Urine Output Last 24 hours Last 8 hours Exam ✔ ‰ Checked box indicates findings are within normal limits ‰Alert ‰Nasal mucosa ‰Dentition ‰Oropharynx Mallampati ‰I ‰II ‰III ‰IV Neck ‰Normal to palpation ‰Thyroid ‰No JVD Resp ‰Clear to auscultation ‰Dullness to percussion ‰No respiratory distress ‰No chest wall defects ‰Decreased fremitus ‰Bronchial breath sounds CV ‰Clear S1 S2 ‰No murmur ‰No gallop ‰No rub ‰Peripheral pulses ‰No peripheral edema GI ‰No palpable masses ‰Liver and spleen not palpable ‰No hepatojugular reflux Lymph ‰No lymphadenopathy Musc ‰Tone ‰Gait Extrem ‰No clubbing ‰No cyanosis Skin ‰No rashes, ecchymoses, nodules, ulcers Neuro ‰Oriented ‰Affect General ENT Glasgow Coma Score E____ V____ M____ APACHE II Score ____ Impression and Plan Schedule Patient For Labs/Tests ‰LFTs ‰Hepatitis Panel ‰HIV ‰TSH ‰CBC ‰BMP ‰D-dimer ‰ESR ‰Phospholipid Ab ‰RF ‰dsDNA Ab ‰ssDNA Ab ‰Centromere Ab ‰Topoisomerase I Ab (Scl-70) ‰U1RNP Ab ‰Jo-1 Ab ‰Pulmonary Function Testing ‰Methacholine Challenge ‰6 Minute Walk Test ‰CXR ‰Chest CT ‰with contrast ‰V/Q Scan ‰ECHO ‰With Bubble study ‰Assess PA pressures ‰Cardiopulmonary Stress Test ‰Sleep Study ‰Bronchoscopy ‰Pneumococcal vaccine ‰Influenza vaccine Signature ‰Patient has completed advanced health care directivesœ47 Health Care Power Of Attorney is Code Status ‰Full code ‰Do Not Attempt Resuscitation ‰Continuous home oxygen Tx Flow rate ____________L/min ‰Concentrator ‰Tank with conservation valve ‰Nasal cannula with reservoir ‰Portable tank ‰Gas ‰Liquid ‰Supplemental oxygen therapy during air travel Flow rate ____________L/min Home ‰CPAP ‰BiPAP Flow rate ____________L/min ‰Heater and humidifier Mask type ‰Nasal ‰Oronasal ‰Face ©MB and RR 2006, 2007 Revised 26Sep07



New Chest Pain MedicalTemplate

Our new chest pain evaluation MedicalTemplate was released 10/01/07.

Download sample chest pain SOAP or progess note template


This new MedicalTemplate is suitable for any health care provider that manages patients with chest pain in inpatient and ambulatory settings.

The American Heart Association reports that 8.9 Million people experience angina (cardiac chest pain) each year, and that 400,000 new cases of angina are diagnosed each year. Angina is the most common symptom of heart disease, which is the leading cause of death for men and women in the United States. The CDC reports that 29% of the deaths in 2002 (the most recent year with published statistics) were due to heart disease. More women than men died of heart disease in 2002.

Because of the prevalence and significance of cardiac related chest pain, a comprehensive cardiac evaluation forms the cornerstone of any chest pain evaluation. However, other causes of chest pain such as pulmonary embolisim, pneumonia, pericarditis, esophagitis, and aortic dissection must also be considered.

September 27, 2007

How to reclaim money your practice may be throwing away




Slideshow Transcript
Slide 1: How To Reclaim Money Your Practice May Be Throwing Away The Cost of Inadequate Documentation and Incorrect Coding e-medtools.com

Slide 2: Basic Premises Most physicians Are not practicing medicine “for the money!”  Are competent, compassionate doctors  Enjoy helping others  Work long, hard, often thankless hours  Deserve the money they earn! 

Slide 3: Stressors Physicians Experience Rising clinic practice costs Generally 40-60% of a physician’s revenue Practice costs expected to increase 20% in 2008 Decreased reimbursement from insurance companies Increasingly complex medical field Increased requirements and cost for maintaining licensure Increased pressure to improve quality without compensation Exorbitant, rising medical liability costs and jury awards Increasing violence directed at healthcare workers 28% of ED physicians are assaulted each year Annals of Emergency Medicine 2005 46(2):142-7

Slide 4: Additional Stressors Unrealistic expectations from the general public, legislators, lawyers, and insurance companies Idealistic, virtually perfect performance from physicians Quality is an unfunded mandate! Essentially free medical care is a “moral imperative” (Hillary Clinton’s, 2008 Presidential Candidate, address to George Washington University Medical News Today May 2007) Healthcare providers will bear the cost of public health Emergency departments must treat all people who walk through their doors regardless of ability to pay Hospitals require that doctors be on call for the emergency department in order to have the privilege of working at that hospital Doctors must then see patients who cannot pay for their care

Slide 5: There is No Free Lunch Food, Shelter, Clothing and Healthcare Should the government provide these for free? Should businesses be required to provide these for free? Why should doctors provide free healthcare?

Slide 6: What Physicians Already Do “Physicians are an important source of healthcare for many uninsured and underinsured patients, as evidenced by the fact that a physician’s office is the usual source of care for about one third of uninsured persons, and physician uncompensated care costs were estimated as high as $11 billion in 1994” Managed Care and Physicians’ Provision of Charity Care JAMA 1999 281:1087-1092 Physician Survey (American Medical News 2006) 76% of physicians provided free or low cost healthcare in 1996-97 68% of physicians provided free or low cost healthcare in 2004-2005 Physicians spent 10.6 hours/week providing uncompensated care! “A Growing Hole in the Safety Net: Physician Charity Care Declines Again” Center for Studying Health System Change 2006

Slide 7: Impact of Physician Stressors Medical practices are BUSINESSES!  – A business is not sustainable unless income exceeds expenses – Unlike most businesses, medical practices (physicians) are legally restricted in setting fees for services Reimbursement for physician services are decreasing,  therefore physicians must – See more patients to sustain the medical practice – Spend less time with individual patients in order to see more patients The consequences of an increased workload can result in  – An increased likelihood of missing problems – Decreased patient satisfaction – A significant drop in physician job satisfaction – Hastened “burnout”

Slide 8: To Err Is Human . . . But Don’t Err On Insurance Documentation! Incorrect billing for the documentation provided  Regardless of the complexity, lack of clarity, and unending changes made IS ASSUMED TO BE FRAUD! to the system And can turn a doctor into a criminal! In less time than it takes to receive payment from the Centers for Medicare and Medicaid!

Slide 9: The Injustice Demands from insurance companies are increasing -more paperwork, denial hassles, phone calls, audits, etc. Meanwhile Physician practice costs have  increased by 20% since 2001 (AMA) Health insurance costs have nearly doubled  Yet insurance companies are reducing reimbursement to physicians! – By 2013 it is predicted that Medicare reimbursement will be 50% of the reimbursement seen in 1991! (Vital Signs March 2005) – 2008 Medicare cuts will average 9.9% (AMA) – 5% cuts are planned for 2009 (AMA News, Aug 2007)

Slide 10: How Can Physicians Afford To Work? Give up coveted independence in favor of employed positions?! Stop seeing Medicare and Medicaid patients?! (MMWR 56(10);230) In 2004 20% of physicians no longer accepted Medicare patients 9.3% no longer accepted Medicaid 60% of physicians interviewed in 2007 by the AMA state that they will limit the number of new Medicare patients as a result of aggressive, proposed cuts to physician reimbursement (AMA) Surviving requires understanding AND playing the insurance game! Maximize reimbursement through Adequate and thorough documentation Appropriate Coding Get Paid For The Work You Do!

Slide 11: Many Physicians Under Code! Most physicians do more work than their documentation supports! And, as the saying goes, if it isn’t documented, it didn’t happen! Fear of fines and loss of licensure have forced physicians into under-coding!

Slide 12: How Much Is At Stake? 33-52% of patient encounters are under coded (JABFP 2001;14:184-92 and FPM October 2003 “How to get all the 99214s you deserve”) Assumptions $30 difference in reimbursement (99213 to a 99214) 30 patients per day = lose ~$300 per day! [33%(30 patients/day) x $30/patient = $300/day] For a physician working 5 days/week for 50 weeks, that is $75,000 annually per physician!!! That’s no small chunk of change!

Slide 13: What Is The Gain? Decreasing billing and coding errors by just 50%  could mean an increase of nearly $40,000 per year in practice revenues! The equivalent of seeing an additional 775 (99213) patients/year  Or, an extra 3 patients/day!  WITHOUT THE EXTRA WORK!  $40,000 per year / $58 per patient = 690 patients per year  690 patients per year / 250 work days per year ~ 3 patients per day  Put another way . . .  Losing $300 per day is like seeing nearly 3 new patients per day for free! ($90 per each 99203 new patient) This won’t make physicians rich! This merely decreases the impact of ongoing losses due to decreasing reimbursement and shifting healthcare costs!

Slide 14: Tools to Improve Documentation Electronic Medical Records (EMRs)  – Electronic medical records are available, but are often cost-prohibitive Standardized forms  – Proven to improve documentation – Less expensive – Most are designed to be completed by hand and kept in a paper chart – Many are specific for particular complaints  such as cough, sore throat, etc.,  yet lack the scope needed to address multiple comorbidities – Few contain reminders Physician Quality Reporting Initiatives  Risk of excessive alcohol intake  Severity index scoring, etc. 

Slide 15: Electronic Medical Records In 2004 President Bush created the Office of the  National Coordinator for Health Information Technology whose mission is to – “Implement an interoperable health information technology infrastructure nationwide” System costs  – Software, hardware, training, implementation, ongoing maintenance and support Induced costs  – Costs involved in the transition to an electronic medical record, such as the temporary decrease of productivity A Cost Benefit Analysis of Electronic Medical Records in Primary Care The American Journal of Medicine 2003 114(5):397-403 E-Health 101:Electronic Medical Records Reduce costs, Improve care, and Save lives American Electronics Association 2006

Slide 16: Electronic Medical Records Capabilities May Include* Viewing  – Medical notes, labs, reports, formularies Documenting  – Medical notes, labs, reports Ordering  – Prescriptions, labs, tests, consults, durable medical equipment Messaging  – Physician-Staff; Physician-Physician; Physician-Patient and vice versa Care Management/Follow up  Analysis and Reporting  – Adverse drug reactions, drug-drug reactions, chronic disease reminders, preventive care reminders, statistical analysis Patient-directed  Billing and Scheduling  * All capabilities are not available for all EMR systems

Slide 17: Who Uses Electronic Medical Records? ~ 25% of office-based physicians used some form of EMR in 2005 National Center for Health Statistics National Ambulatory Medical Care Survey

Slide 18: Implementing Electronic Medical Records $2,500 - $44,000 initial start-up cost/provider  – Software  50-200% of initial costs – Hardware  $5,000-10,000/provider – Implementation  $3400/provider – Additional maintenance costs  $700-1500/provider per month  Providers include MD, NP, RN, LPN, PA, MA, receptionist Lost productivity estimated at >$10,000 in the first year  Average time to return on investment is 2.5 years  – This makes electronic medical records unobtainable by most medical practices The Value of Electronic Health Records in Solo or Small Group Practices Health Affairs 2005 24(5):1127-1137 A Cost Benefit Analysis of Electronic Medical Records in Primary Care The American Journal of Medicine 2003 114(5):397-403 Electronic Medical Records Systems Cost Effective, Study Shows Medical News Today 2007

Slide 19: Benefits of Electronic Medical Records Improved documentation  Reduce paper chart pulls  – Estimated to cost $5/chart Decrease costs for transcription  Reduce redundant labs and tests ordered  Some provide prompters  – Preventive care – Medication options – Adverse drug interactions A Cost Benefit Analysis of Electronic Medical Records in Primary Care The American Journal of Medicine 2003 114(5):397-403

Slide 20: Financial Benefits of EMRs 5-year net BENEFIT of a “full EMR”  – $86,000/provider – Full EMR includes electronic prescriptions, chronic disease reminders, drug interactions, and preventive care prompters 5-year net COST of a “light EMR”  – $18,000/provider – used only to reduce paper chart pulls and transcription costs A Cost Benefit Analysis of Electronic Medical Records in Primary Care The American Journal of Medicine 2003 114(5):397-403

Slide 21: MedicalTemplates Standardized patient encounter forms   Adobe PDF Technology – Use as a paper form OR – Use as an electronic form

Slide 22: MedicalTemplates Features Documentation prompters  – HCFA 1997 documentation guidelines Quality reminders  – Medicare PQRI Checkboxes  – Save time – Save energy – Time is Money

Slide 23: Implementing MedicalTemplates Required Hardware and Software – Free Adobe Reader from Adobe.com – Basic computer ($350 or less)  Intel Pentium III or better for Windows  PowerPC G3 or better for MacOS – One or more MedicalTemplates  $150 per template

Slide 24: MedicalTemplate Benefits Inexpensive implementation   Minimal learning curve  Improved documentation  Reduce paper chart pulls (if using electronic format) – Estimated to cost $5/chart Decrease costs for transcription   Prompters/Reminders improve – Preventive care – Quality of care – Treatment options – Evaluation options

Slide 25: MedicalTemplates ROI Assumptions Template cost $150 per practitioner  Computer cost $350 (most offices already have >1 computer)  Baseline under coding rate 30%  ($300 lost revenue/day) Reduction in under coding 50%  – If 33% of 30 patients seen in one day are under coded  10 patients are under coded by $30 apiece = $300/day  A 50% reduction = Only 5 patients are under coded  Increased revenue = $30 x 5 patients now coded correctly = $150 Increased revenue of $150/day equates to a savings of  $750/week $3000/month >$36,000/year! At $150 per template, the template pays itself off in 1 day!

Slide 26: MedicalTemplate ROI Calculation Including Computer Costs In just 1 month, the Return On Investment (ROI) could be: Average improvement in reimbursement in 1 month X 100 = ROI Cost of Template + Cost of Computer $3000 X 100 = 600% $150 + $350

Slide 27: MedicalTemplate ROI Calculation Without Computer Costs In just 1 month, the Return On Investment (ROI) could be: Average improvement in reimbursement in 1 month X 100 = ROI Cost of Template $3000 X 100 = 2,000% $150

Slide 28: Time to Recover Cost of MedicalTemplate MedicalTemplate + Computer ($500) $500/$150 ~ 3 days MedicalTemplate without Computer ($150) $150/$150 = 1 Day!

Slide 29: Savings Not included in ROI Estimates Reductions in down coding   Reductions in claim denials  Reduced time spent on documentation  Reduced time pulling charts

Slide 30: MedicalTemplates General forms Problem specific forms Clinic H&P Asthma   Clinic Follow Up Note COPD   Hospital H&P Pneumonia   Hospital Follow Up Pleural Effusion   Pulmonary/Critical Care H&P  Lung Mass  Pulmonary/Critical Care Follow  Interstitial Lung Disease  Up Chest Pain  Pulmonary Clinic H&P  Pulmonary Hypertension 

Slide 31: MedicalTemplates MedicalTemplates has created multiple medical templates appropriate for evaluating patients in the clinic or hospital setting. MedicalTemplates are fillable PDF forms that allow the physician to type historical information directly into the form. They can be saved electronically for later reference. Documentation time is decreased Most components of the history and physical exam can be completed by checking the appropriate box. Reducing documentation time by 5-10 minutes per patient could save the physician >2 hours per day! 30 patients / day x 5 minute decrease / patient = 2.5 hours / day SAVED!


GenericMedList added to the dotMobi Showcase

GenerciMedList.mobi has been added to the dotMobi Showcase at http://mtld.mobi/showcase, and has scored 5/5 at Ready.Mobi

The .mobi domain requires the use of stringent W3C-based standards to ensure a high quality mobile user experience. GenericMedList.Mobi was developed with MobiSiteGalore publishing tools and delivers GenericMedList to mobile users.


End of introductory pricing for MedicalTemplates

Introductory pricing for MedicalTemplates will end Sept. 30, 2007.

Effective October 1, 2007 the pricing for MedicalTemplates will be -

  • $150 for an individual practitioner license
  • $400 for a 3-5 practitioner license
  • $1000 for a unlimited practitioner license

August 20, 2007

Generic Medication Discount Database

We have launched a searchable generic medication discount program list on GenericMedList.Com.

This list can be searched by medication name, and will return discount programs and prices for that generic medication.

Discount programs from Walmart, Target, Publix, and Meijer stores are currently featured in the database.

GenericMedList is a valuable resource healthcare consumers and professionals concerned about the high cost of medications.

August 9, 2007

MedSpel Web Site

MedSpel now has its own web site - www.medspel.com

MedSpel is an award winning medical spelling tool for Microsoft Word that was recently updated to be compatible with Windows Vista and Office Vista.

MedSpel adds over 40,000 medical terms to the Microsoft Word spellchecker.

This new addition will mirror the official e-MedTools MedSpel section at this time.

A log in area to download updates is in the works for registered users.

July 16, 2007

Hospital Follow Up MedicalTemplate Updated 7/16/07

The hospital follow up MedicalTemplate has been updated with a new layout.

The hospital follow up MedicalTemplate sample can be downloaded from here.

Download hospital follow up medical note template

July 11, 2007

Quality Measures for the Medicare 2007 PQRI Program

This comprehensive presentation reviews the quality measures that are part of the 2007 Medicare Physician Quality Reporting Initiative (PQRI).





Slideshow Transcript

Slide 1: Centers for Medicare & Medicaid Services 2007 Physician Quality Reporting Initiative (PQRI) Coding for Quality: The Measures Module IV June 13, 2007 1

Slide 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. 2

Slide 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. 3

Slide 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 4

Slide 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. 5

Slide 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 6

Slide 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 7 Report Procurement Sensitive 7

Slide 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. 8

Slide 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). 9

Slide 10: Coding for Quality: PQRI Tools Implementing PQRI 10

Slide 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. 11

Slide 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 12

Slide 13: PQRI Tools: The Measure List 13 Procurement Sensitive 13

Slide 14: PQRI Tools: MLN 5640: Coding and Reporting Principles 14 Procurement Sensitive 14

Slide 15: PQRI Tools: Coding for Quality A Handbook for PQRI Participation 15 Procurement Sensitive 15

Slide 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 16

Slide 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 17

Slide 18: PQRI Tools: Measure- specific Data Collection Worksheets • Measure Specific – Measure Description – Worksheet – Coding Specifications 18

Slide 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. 19

Slide 20: Coding for Quality: PQRI Principles Understanding the Measures 20

Slide 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 21

Slide 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 22

Slide 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) 23

Slide 24: Understanding the Measures: Construct CPT II Code or Temporary G Code ________________________________ ICD-9-CM and CPT Category I Codes 24

Slide 25: Understanding the Measures: Quality Data Codes Quality-Data Codes translate clinical actions so they can be captured in the administrative claims process 25

Slide 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) 26

Slide 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. 27

Slide 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 28

Slide 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. 29

Slide 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 30

Slide 31: Coding for Quality: PQRI Coding Examples Of Measures 31

Slide 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. 32

Slide 33: Coding for Quality: Example #1- Prevention Measure #4 – Screening for Future Fall Risk 33

Slide 34: 34 Procurement Sensitive 34

Slide 35: 35 Procurement Sensitive 35 Current Procedural Terminology © 2006 American Medical Association. All Rights Reserved.

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

Slide 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) 37 Procurement Sensitive 37

Slide 38: 38 Procurement Sensitive 38

Slide 39: Tool: Worksheet 39 Procurement Sensitive Current Procedural Terminology © 2006 American Medical Association. All Rights 39 Reserved.

Slide 40: Current Procedural Terminology © 2006 American Medical Association. All Rights Reserved. 40 Procurement Sensitive 40

Slide 41: Coding for Quality: Example #3- Acute Episode of Care Management Measure #55 – Electrocardiogram (ECG) Performed for Syncope 41 Procurement Sensitive 41

Slide 42: 42 Procurement Sensitive 42

Slide 43: 43 Procurement Sensitive Current Procedural Terminology © 2006 American Medical Association. All Rights 43 Reserved.

Slide 44: Current Procedural Terminology © 2006 American Medical Association. All Rights Reserved. 44 Procurement Sensitive 44

Slide 45: Coding for Quality: Example #4- Procedural Related Care Measure # 20 – Timing of Antibiotic Prophylaxis – Ordering Physician 45 Procurement Sensitive 45

Slide 46: 46 Procurement Sensitive 46

Slide 47: 47 Current Procedural Terminology © 2006 American Medical Procurement Sensitive Association. All Rights Reserved. 47

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

Slide 49: Current Procedural Terminology © 2006 American Medical Association. All Rights Reserved. 49 Procurement Sensitive 49

Slide 50: Coding for Quality: Example #5-Resource Utilization Measure #66 – Appropriate Testing for Children with Pharyngitis 50 Procurement Sensitive 50

Slide 51: 51 Procurement Sensitive 51

Slide 52: 52 Procurement Sensitive 52 Current Procedural Terminology © 2006 American Medical Association. All Rights Reserved.

Slide 53: Current Procedural Terminology © 2006 American Medical Association. All Rights Reserved. 53 Procurement Sensitive 53

Slide 54: Coding for Quality: Example #6- Care Coordination Measure # 47– Advance Care Plan 54 Procurement Sensitive 54

Slide 55: 55 Procurement Sensitive 55

Slide 56: 56 Procurement Sensitive Current Procedural Terminology © 2006 American Medical Association. All 56 Rights Reserved.

Slide 57: Current Procedural Terminology © 2006 American Medical Association. All Rights Reserved. 57 Procurement Sensitive 57

Slide 58: Coding for Quality: PQRI Readiness Ensuring Success 58

Slide 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. 59 Current Procedural Terminology © 2006 American Medical Association. All Rights Reserved.

Slide 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. 60 Current Procedural Terminology © 2006 American Medical Association. All Rights Reserved.

Slide 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 61



Medicare PQRI Coding Guidance Presentation

This presentation provides an overview of the coding rules related to the 2007 Medicare Physician Quality Reporting Initiative (PQRI) program.



Slideshow Transcript

Slide 1: Centers for Medicare & Medicaid Services 2007 Physician Quality Reporting Initiative (PQRI) Coding Guidance Module III May 24, 2007 1

Slide 2: Overview • Value-Based Purchasing and the PQRI • PQRI Introduction: Information about PQRI • PQRI Reporting: Understanding the Measures • PQRI Reporting: Coding for Quality • PQRI Implementation: Practice Readiness • PQRI Support: Educational Tools and Resources 2

Slide 3: Value-Based Purchasing and PQRI • 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. 3

Slide 4: Quality and PQRI • PQRI reporting will focus attention on quality of care. – Foundation is evidence-based measures developed by professionals. – Reporting data for quality measurement is rewarded with financial incentive. – Measurement enables improvements in care. – Reporting is the first step toward pay for performance. 4

Slide 5: PQRI Introduction: The Statute • Tax Relief and Healthcare Act (TRHCA) Division B, Title I, Section 101 provides statutory authority for PQRI and defines: – Eligible professionals – Quality measures – Form and manner of reporting – Determination of satisfactory reporting – Bonus payment calculation – Validation – Appeals 5

Slide 6: PQRI Introduction: 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 6

Slide 7: PQRI Introduction: Eligible Professionals • • Physicians Practitioners – MD/DO – Physician Assistant – Podiatrist – Nurse Practitioner – Optometrist – Clinical Nurse – Oral Surgeon – Specialist – Dentist – Certified Registered Nurse – Chiropractor – Anesthetist • Therapists – Certified Nurse Midwife – Physical Therapist – Clinical Social Worker – Occupational Therapist – Clinical Psychologist – Qualified Speech- – Registered Dietician Language Pathologist – Nutrition Professional 7

Slide 8: PQRI Introduction: The Quality Measures • Final list of 74 quality measure statements, descriptions, and detailed specifications now posted at: www.cms.hhs.gov/PQRI. • Specifications will be updated and reposted prior to the July 1, 2007 start date to expand the applicability of the measures. 8

Slide 9: PQRI Introduction: Successful Reporting • If 4 or more measures are applicable to the practice, practitioner must report at least 3 of them correctly for 80 percent of cases (visits or patients, depending on measure). • If 3 or fewer measures are applicable to the practice, practitioner must report each of them correctly for 80 percent of the cases (visits or patients, depending on measure). 9

Slide 10: PQRI Introduction: The Bonus Payment • Professionals that report successfully are eligible for a 1.5 percent bonus payment, subject to a cap. • Potential bonus payment is calculated using total allowed charges for covered professional services furnished during the reporting period and paid under the Physician Fee Schedule. • The cap will be calculated at the end of the reporting period by multiplying the National Average per Measure Payment Amount (National total charges associated with quality measures /National total instances of reporting) x 300% x Individual’s instances of reporting quality data. 10

Slide 11: PQRI Introduction: Validation and Appeals • Validation – The statute requires CMS to use sampling or other means to validate whether the required minimum number of quality measures applicable to the services have been reported. • Appeals – The statute excludes PQRI-related determinations from formal administrative or judicial review. 11

Slide 12: 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). 12

Slide 13: PQRI Introduction: The Tools • Gather information and educational materials from the PQRI website ( www.cms.hhs.gov/pqri). • Change Request 5640 (effective May, 18, 2007) Coding and Reporting Principles • Gather information from other sources, such as your professional association, specialty society or the American Medical Association. 13

Slide 14: PQRI Reporting Understanding the Measures 14

Slide 15: PQRI Reporting: Select Measures • Review the 2007 PQRI measures list and specifications at: www.cms.hhs.gov/PQRI. – Click on the Measures/Codes link – Go to Downloads • Select measures that address the services you provide to patients. – Conditions you treat – Types of care you provide – e.g., preventive, chronic, acute – Settings of care for your work – e.g., office, ED, surgical suite • Consider your quality improvement goals for 2007. 15

Slide 16: PQRI Reporting: Understanding the Measures • 74 unique measures associated with clinical conditions that are routinely represented on Medicare Fee-for-Service (FFS) claims through the use of diagnosis codes from ICD-9-CM and procedural codes from the Health Care Common Procedure Coding System (HCPCS) 16

Slide 17: PQRI Reporting: Understanding the Specifications • The Specifications describe specific measures and associated codes that address various aspects of care: – Prevention – Chronic Care Management – Acute Episode of Care Management – Procedural Related Care – Resource Utilization – Care Coordination 17

Slide 18: PQRI Reporting: Understanding the Specifications • 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 18

Slide 19: PQRI Reporting: Understanding the Specifications • Some measures have a Performance Timeframe related to the clinical action that may be distinct form the reporting frequency. These may be stated: – Perform within 12 months – Most recent 19

Slide 20: PQRI Reporting: Understanding the the Quality Data Codes • CPT II codes (or temporary G codes used on an exception basis where CPT II codes have not yet been developed) • Quality Data Codes translate clinical actions so they can be captured in the administrative claims process. 20

Slide 21: PQRI Reporting: Understanding the the Quality Data Codes • Quality Data Codes can relay that: – The measure requirement was met – The measure requirement was not met due to documented allowable performance exclusions (i.e., using performance exclusion modifiers) – The measure requirement was not met and the reason is not documented in the medical record (i.e., using the 8P reporting modifier) 21

Slide 22: PQRI Reporting: Understanding the the 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. 22

Slide 23: PQRI Reporting: Understanding the the Modifiers • 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 23

Slide 24: PQRI Reporting Coding for Quality 24

Slide 25: PQRI Reporting: Coding for Quality • Anti-platelet Therapy Prescribed for Patients with Coronary Artery Disease • Advanced Care Planning • Perioperative Care: Timing of Antibiotic Prophylaxis- Ordering Physician 25

Slide 26: Successful Reporting Scenario Oral Anti-platelet Therapy Prescribed for Patients with Coronary Artery Disease Measure #6 • Performance Description: Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease who were prescribed anti-platelet therapy* • Reporting Description: Percentage of patients aged 18 years and older seen by the clinician and an applicable CPT Category II code reported once per reporting period for patients seen during the reporting period *Anti-platelet therapy consists of aspirin, clopidogrel/Plavix or a combination of aspirin and dypyridamole/Aggrenox. 26

Slide 27: Successful Reporting Scenario Oral Antiplatelet Therapy Prescribed for Patients with Coronary Artery Disease Mr. Jones presents for office visit with Dr. Thomas Mr. Jones has diagnosis of CAD Situation 3: Situation 1: Situation 2: There is no Dr. Thomas documents Dr. Thomas documentation that Dr. that antiplatelet therapy documents that Mr. Thomas or other is contraindicated for Jones is receiving eligible professional Mr. Jones because he antiplatelet therapy. addressed antiplatelet has a bleeding therapy for Mr. Jones. disorder. CPT II code CPT II code 4011F- 4011F-1P modifier CPT II code 4011F* 8P modifier *All of these situations represent successful 2007 PQRI reporting. Current Procedural Terminology © 2006 American Medical Association. All Rights Reserved. 27

Slide 28: Successful Reporting Scenario Advanced Care Plan Measure #47 • Performance Description: Percentage of patients aged 65 years and older with documentation of a surrogate decision-maker or advanced care plan in the medical record • Reporting Description: Percentage of patients aged 65 years and older seen by the clinician and an applicable CPT Category II code reported a minimum of once during the reporting period* *This measure is appropriate for use in all healthcare settings. 28

Slide 29: Successful Reporting Scenario Advanced Care Plan A 70 year old male patient presents to the clinician for medical care. Scenario 1: Scenario 2: Scenario 3: The clinician asks if the There is no documentation The clinician documents in patient has an advanced that clinician discussed a the chart that the patient does care plan or surrogate surrogate decision maker or not wish to discuss advanced decision-maker. Clinician advanced care plan, no care planning. documented an advanced reason is specified. care plan in the chart. CPT II code 1080F-2P CPT II code 1080F-8P modifier CPT II code 1080F modifier All of these scenarios represent successful 2007 PQRI reporting. Current Procedural Terminology © 2006 American Medical Association. All Rights Reserved. 29

Slide 30: Successful Reporting Scenario Perioperative Care: Timing of Antibiotic Prophylaxis- Ordering Physician Measure #20 • Performance Description: Percentage of surgical patients aged 18 years and older undergoing procedures with the indications for prophylactic parenteral antibiotics, who have an order for prophylactic antibiotic to be given within one hour (if fluoroquinolone or vancomycin, two hours), prior to the surgical incision (or start of procedure when no incision is required • Reporting Description: Percentage of surgical patients aged 18 years and older undergoing procedures with the indications for prophylactic parenteral antibiotics and applicable CPT Category II code reported each time a procedure is performed during the reporting period 30

Slide 31: Successful Reporting Scenario Perioperative Care: Timing of Antibiotic Prophylaxis-Ordering Physician A 70 year old female presents to the operating room for scheduled abdominal surgery. Scenario 1: Scenario 2: Scenario 3: Documentation of Documentation of medical Order for prophylactic perioperative order for reason for not ordering antibiotic not documented, appropriate prophylactic antibiotic therapy within the no reason specified. antibiotics within one hour specified time frame. of surgical incision time(two CPT II code 4047F- CPT II code 4047F - hours if fluoroquinolone or 8P modifier vancomycin). 1P modifier CPT II code 4047F All of these scenarios represent successful 2007 PQRI reporting. Current Procedural Terminology © 2006 American Medical Association. All Rights Reserved. 31

Slide 32: PQRI Reporting: Data Submission • CPT Category II codes (or temporary G- codes) may be reported on paper-based 1500 or electronic 837-P claims. • The CPT Category II code, which supplies the numerator, must be reported on the same claim form as the payment ICD-9 and CPT Category I codes, which supply the denominator of the measures. • Multiple CPT Category II codes can be reported on the same claim, as long as the corresponding denominator codes are also on that claim. 32

Slide 33: PQRI Reporting: Data Submission • Submitted charge field cannot be blank – Line item charge should be $0.00 – If system does not allow $0.00 line item charge, use a small amount like $0.01. • Entire claims with a zero charge are rejected. • Quality data code line items will be denied for payment but then passed through to the NCH file for PQRI analysis. 33

Slide 34: PQRI Reporting: Data Submission • The individual NPI of the participating professional must be properly used on the claim. • Multiple Eligible Professionals with their NPIs may be reported on the same claim with each quality data code line item corresponding to the services rendered by the professional for that encounter. • All claims must reach the NCH file by February 29, 2008 to be included in the bonus calculation. 34

Slide 35: 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. 35

Slide 36: PQRI Implementation Practice Readiness 36

Slide 37: PQRI Implementation: Developing Reporting Process • Identify team that will develop reporting process; include members of office staff as well as clinical practitioners. • Review steps for ongoing reporting in light of selected measures. • Consider what changes will need to be made to practice systems for each step. • Consider using worksheets, encounter forms, screen templates, or other tools for data capture. 37

Slide 38: Description 38

Slide 39: Worksheet 39

Slide 40: Coding Specifications Current Procedural Terminology © 2006 American Medical Association. All Rights Reserved. 40

Slide 41: PQRI Implementation: Modifying Practice Systems • Depending on the reporting system you have developed, you may need to: – Adopt, modify or create PQRI worksheets (use or modify CMS worksheets or those created by a third party, if available) – Adopt, modify or create billing sheet/encounter forms – Adopt, modify or create other paper materials – Modify fields or capabilities of electronic medical records (EMR) system to include G-codes and/or CPT-II codes or other capabilities – Modify billing system to accept $0.00 or $0.01 charges for line items with quality codes – Improve documentation of care provided 41

Slide 42: PQRI Implementation: Test System Readiness • 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. 42

Slide 43: PQRI Implementation: Test System Readiness • For paper claims, report the test code in field 24D on the CMS 1500 Form. • On the ASCX12N electronic health care claim transaction (version 4010A1), enter the test code in the SV101-2 “Product/Service ID” Data Element on the SV1 “Professional Service” Segment of the 2400 “Service Line” Loop. It is also necessary to identify in this segment that a HCPCS code is being supplied by submitting the HC in data element SV101-1 within the SV1 “Professional Service” Segment. • All necessary fields must be reported on the line for the test code just the same as they are for other codes, on the CMS 1500 Form and on the ASCX12N electronic health care claim transaction (version 4010A1). 43

Slide 44: PQRI Implementation: Test System Readiness • Reminder: NPIs will need to be included on the line level for the claims to be used in the PQRI analysis. • Providers are encouraged to use this time to get into the habit of reporting line-level NPI information. 44

Slide 45: PQRI Support: Educational Tools and Resources • Engagement through communication – CMS PQRI website contains all publicly available information at: www.cms.hhs.gov/PQRI – Medicare Carrier/Medicare Administrative Contractor (MAC) inquiry management • Educational materials 45

Slide 46: PQRI Support: Educational Tools and Resources • Educational materials to be available soon on the PQRI website: – Final Specifications – New Frequently Asked Questions – PQRI Code Master – Individual Measure Worksheets – 2007 PQRI Participation Handbook 46



July 8, 2007

Medicare PQRI Provider Call Presentation



This Medicare PQRI Provider Call presentation was released April 5, 2007 and provides a good overview of the Medicare 2007 Physician Quality Reporting Initiative (PQRI).

The presentation can be downloaded from here>


Presentation Transcript

Slide 1: Centers for Medicare & Medicaid Services 2007 Physician Quality Reporting Initiative (PQRI) National Provider Call March 27, 2007 1

Slide 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. 2

Slide 3: Disclaimers The Medicare Learning Network (MLN) is the brand name for official CMSCMS 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. 3 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

Slide 4: 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 4

Slide 5: Physician Quality Reporting Initiative (PQRI) • Eligible Professionals – Medicare physician, as defined in Social Security Act (SSA) Section 1861(r): • Doctor of Medicine • Doctor of Osteopathy • Doctor of Podiatric Medicine • Doctor of Optometry • Doctor of Oral Surgery • Doctor of Dental Medicine • Chiropractor 5

Slide 6: Physician Quality Reporting Initiative (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 6

Slide 7: Physician Quality Reporting Initiative (PQRI) • Eligible Professionals – Therapists • Physical Therapist • Occupational Therapist • Qualified Speech-Language Pathologist 7

Slide 8: Physician Quality Reporting Initiative (PQRI) • Eligible Professionals – All Medicare-enrolled eligible professionals may participate, regardless of whether they have signed a Medicare participation agreement to accept assignment on all claims – No registration is required to participate in PQRI. 8

Slide 9: Physician Quality Reporting Initiative (PQRI) • Quality Measures – 66 “2007 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 posted at www.cms.hhs.gov/PQRI, as a download on the Measures/Codes webpage – Detailed measure specifications and instructions will be posted well in advance of July 1, 2007 statutory deadline 9

Slide 10: Physician Quality Reporting Initiative (PQRI) • Form and Manner of Reporting – Reporting period is July 1—December 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 are reported with a $0.00 charge • 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 10

Slide 11: Quality-Data Codes: From Care Process to Claim ADMINISTRATIVE CLINICAL 3. Quality code associated with the measure is captured for 1. During a visit, patient is claims submission process identified as eligible for reporting based on clinical 5. Billing staff enter quality-code condition data on claims in the same location used for other HCPCS 2. Eligible professional code reporting: documents medical record – 837 Electronic Claims: and documentation fulfills SV1 “Professional Service” measure requirements Segment of the 2400 “Service Line” Loop, SV101-1, SV101-2 OR – CMS 1500: Field 24D 11

Slide 12: CMS 1500 Paper Claim Form www.cms.hhs.gov/cmsforms/ 12

Slide 13: Quality-Data Code Charges • Submitted charge field cannot be left blank. • Submitted line item charge should be $0.00. • If billing software does not accept a $0.00 line item charge, a small amount can be substituted. • Eligible professionals can not collect any monies from beneficiaries for quality-data codes. 13

Slide 14: Physician Quality Reporting Initiative (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 14

Slide 15: Physician Quality Reporting Initiative (PQRI) • Determination of Successful Reporting – Analysis is expected to be performed at the individual level • Requires accurate and consistent use of individual National Provider Identifier (NPI) on claims • www.cms.hhs.gov/NationalProvIdentStand 15

Slide 16: Physician Quality Reporting Initiative (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 coinsurance 16

Slide 17: Physician Quality Reporting Initiative (PQRI) • Bonus Payment – Cap may apply when relatively few instances of quality measures are reported – Cap calculation = 1. (Individual’s instances of reporting quality data) X 2. (300%) X 3. (National average per measure payment amount) National average per measure payment amount = (National charges associated with quality measures) / (National instances of reporting) 17

Slide 18: Physician Quality Reporting Initiative (PQRI) • 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 18

Slide 19: Physician Quality Reporting Initiative (PQRI) • 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 during 2007 – Reports are expected to include reporting and performance rates 19

Slide 20: Physician Quality Reporting Initiative (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 20

Slide 21: Physician Quality Reporting Initiative (PQRI) • 2008 Considerations – Registry-based and electronic record- based reporting • Short lead time for implementation precludes using these channels for 2007 PQRICMS is working toward opening these channels for 2008 reporting • Standardized specifications for centralized reporting could reduce the burden of reporting for participants and CMS 21

Slide 22: Physician Quality Reporting Initiative (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 – Tools to support successful reporting 22