Physician Quality Reporting Initiative (PQRI) Information

In March 2007, The Centers for Medicare and Medicaid Services (CMS) established the Physician Quality Reporting Initiative (PQRI), a voluntary program in which physicians collected and reported their practice data in relation to a set of 74 performance measures between July and December 31, 2007.  This voluntary program, which originated as a result of the Tax Relief and Health Care Act of 2006 (TRHCA), is largely considered a precursor to a mandatory pay-for-performance program CMS will roll out within the next two years. 

AAOS has been instrumental in assisting CMS with the development of orthopaedic-related tools for this program, and we continue to be involved in ongoing discussions with CMS on the program’s development. Below are links to information about the program and its technical specifications.  This page will be updated frequently as new information about the PQRI becomes available.

How to Participate in the 2008 Physician Quality Reporting Initiative (PQRI)

The CMS Physician Quality Reporting Initiative (PQRI) begins January 1, 2008 and runs through December 31, 2008. As in 2007, when the program covered only half the calendar year, physicians will again qualify for a bonus if the physician reports on at least three performance measures on 80% of the eligible patients through out the full calendar year. There is an advantage in reporting more than three measures if more than three are available. In some cases, three will not be available and in those cases, you need only report the ones available.

The bonus is calculated as 1 ½ % of all of a physician’s Medicare billings, not just the ones on which he or she reports. This calculation does not include charges for x-ray, MRI, DME or PT. There is a cap for those who report on only a few patients. This article outlines the steps necessary for an orthopaedist to participate.

Reasons to participate:

1. You may earn a bonus of up to 1½ % on all your Medicare billings.
2. PQRI, or some version of it, will likely become mandatory in the next several years. This is a way to learn how to report performance measures without penalties.
3. Private payers are also implanting pay for performance or reporting programs and this is a way to become familiar with the process. You will get a feedback report outlining how accurately you reported.
4. This particular program takes very little effort on your part.

Reasons not to participate:

1. If your practice management billing system or your clearing house will not accept CPT Level II or G-codes, it may cost more to modify your system than you may recover in the bonus payment.
2. If you have to collect data by abstracting medical charts, the costs may outweigh the bonus.

To report the measures, physicians should append the appropriate CPT Level II or G-codes to the CMS 1500 form used to report the service for which the measures are appropriate. For instance, if you are reporting the antibiotic or thromboembolic prophylactic measures, you would append the CPT level II or G-code to the CMS 1500 form used to report the procedure. If you are reporting one of the osteoporosis or fall risk measures, then you would append the CPT Level II or G-code to the CMS 1500 form used to report the appropriate E&M service, frequently 99024, follow-up for a procedure. A physician does not have to be a Medicare participating physician, but the only way to report the measures is on the CMS 1500 form.

Step 1: Ensure that your computerized practice management system can accept CPT Level II or G-codes. These codes are alpha-numeric and some systems will not accept them.

Step 2: If you are using a clearing house or scrubbing service to submit your bills, you must be sure that the service can accept CPT Level II or G-codes, as some cannot. Another potential computer problem is that some systems will not accept a 0 dollar amount in the field following a CPT code. If that is the case in your system, it is easily solved by inserting a small dollar amount, like $1.

Step 3: Develop a systematic method to instruct your billing clerk to append the appropriate CPT Level II or G-codes to the CMS 1500 forms.

Please see the following six worksheets.

1. The first is a 13-page worksheet that includes all of the technical information that is also available on the CMS PQRI web page.
2. The shorter version includes most of that information with some of the details deleted.
3. The third is a two-page sheet that includes all the coding information the billing clerk will need for any of the 13 measures applicable to orthopaedics.
4. The fourth is similar, but contains only the coding information for the four measures that apply to operative procedures. These are the ones that will be most used by orthopaedists.
5. A list of CPT Level II and G-codes.
6. A list of the CPT Level II and G-codes with appropriate modifiers.
   

We suggest you read the longer worksheet so you will have a full understanding of the requirements of participation. Then have your billing clerk use one of the short forms as a reference as he/she appends the appropriate CPT Level II and G-codes to your billing form.

You must report on 80% of all eligible patients. That means that if you choose to report the antibiotic and thromboembolic prophylaxis measures, you must report on all the operative procedures on the list of eligible procedures. Specifically, if you are a total joint doctor, but take emergency call and occasionally do trauma and fractured hips, you must report on them too, not just your total joints.

Some orthopaedists may have difficulty identifying enough measures to report. Orthopaedic surgeons with a practice in hand for instance, would infrequently use thromboembolic prophylaxis and may not routinely use antibiotic prophylaxis. Pediatric orthopaedists may also have difficulty, as the operations they most commonly perform are not on the list of eligible procedures. As pay for performance initiatives move forward, the AAOS will help develop more measures that will cover all orthopaedic sub-specialties.

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 provider’s instances of reporting quality data, as long as it does not exceed 1 ½% of the individual provider’s total Medicare charges for the reporting period.

The mathematical formula would be:

A/B x 3 x C = Bonus

Where:

A = The national total charges associated with quality measures

B = The national total instances of reporting

C = The individual provider’s instances of reporting quality data.

Obviously, the cap cannot be determined until after the reporting period (December 31, 2008) as CMS will not know several of the numbers until the end of the period. The bonus will be paid as a lump sum sometime after the end of the reporting period, probably late spring or early summer in 2009.

The data is collected by CMS using the National Provider Identifier (NPI). If you do not have an NPI, you can apply for one at: https://nppes.cms.hhs.gov/NPPES/Welcome.do. The on-line application takes about five minutes.

By phone:

1-800-465-3203 (NPI Toll-Free)
1-800-692-2326 (NPI TTY)

By e-mail at:

customerservice@npienumerator.com

By mail at:

NPI Enumerator
PO Box 6059
Fargo, ND 58108-6059

The deadline for obtaining an NPI was May 23, 2007. However, the bonus payment in 2008 and 2009 will be made using the payer number. This means that a multi-physicians practice that bills under one payer number will have to decide how to distribute the bonus to the individual physicians.

In the 2008 PQRI there are a total of 119 measures, 13 measures that may apply to orthopaedic surgeons:

4. Screening for Future Fall Risk

20. Perioperative Care: Timing of Antibiotic Prophylaxis - Ordering Physician

21. Perioperative Care: Selection of Prophylactic Antibiotic - First OR Second Generation Cephalosporin

22. Perioperative Care: Discontinuation of Prophylactic Antibiotics (Non-Cardiac Procedures)

23. Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)

24. Osteoporosis: Communication with the Physician Managing Ongoing Care Post Fracture

39. Screening or Therapy for Osteoporosis for Women Aged 65 Years and Older

40. Osteoporosis: Management Following Fracture

41. Osteoporosis: Pharmacologic Therapy

124. HIT – Adoption/Use of Health Information Technology (Electronic Health Records)

125. HIT – Adoption/Use of e-Prescribing

126. Diabetic Foot and Ankle Care, Peripheral Neuropathy: Neurological Evaluation

127. Diabetic Toot and Ankle Care, Ulcer Prevention: Evaluation of Footwear

For a full description of the measures, see the worksheets available on this web page. Also in the worksheets is a description of the CPT Level II and G-codes used to report the measures and a list of the CPT procedure codes for which the measures are appropriate.

There are a few other measures that might be applicable to orthopedic surgeons in unusual circumstances. These include measure number 46, medication reconciliation; measure number 108, disease modifying anti-rheumatic drug therapy in rheumatoid arthritis; measure number 114, inquiry regarding tobacco use; and measure number 115, advising smokers to quit. We have not included these measures in the worksheets, but you may use them.

The PQRI is pay for reporting, not pay for performance. You must only report that you ordered an antibiotic to be given within one hour of the operative procedure. You do not have to ensure that it is given. In the case of measure 22, there need only be an order that the antibiotic is to be discontinued before 24 hours. If you elect not to give an antibiotic for a medical reason, allergy or other medical reason, you need only to report the CPT Level II code with a 1P modifier. If you decided not to give the antibiotic, but for no specific reason, then append modifier 8P. You are reporting, not necessarily doing.

Additional tips:

1. For reporting the CPT Level II and G-codes, the charge field (24f on the CMS 1500 form) must not be blank and must have some amount other than $0. If the field is empty or does not have some amount other than $0 in it, CMS will reject the claim for reporting purposes. For payment purposes, the claim will continue to be processed and it will not impact your payment but it will not be counted in your performance reporting. You must enter some amount. We had attempted to get CMS to include 99024 (follow-up for a surgical procedure in the global period) as one of the E&M codes that would qualify for reporting but since the CMS computers will not accept a $0 in field 24f for PQRI reporting purposes, they could not include it. If you are reporting any of the antibiotic or thromboembolic measures, this should not be a problem since you will be reporting the measures with a procedure code and it will naturally have a dollar amount is field 24f. However, if you are reporting on one of the osteoporosis measures, and you are reporting it in the post op global period, you must do so on a CMS 1500 form that has some E&M code with an amount. We have asked CMS if this can be done with an x-ray code, but have not had a ruling from them as yet.
2. CMS has provided a way to test your systems reporting ability at this time. You only need to report a test G code, G8300, on several of your routine claim forms. 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. You will get an error message on your EOB but that will confirm that you system is properly reporting the code.
3. As stated earlier, you must report using the NPI. You should have already obtained an NPI for each physician.
4. We have identified a problem in the antibiotic codes regarding revision total hip surgery. In measure #20, CPT codes 27137 and 27138 are listed as codes that require an order for a prophylactic antibiotic to be administered one hour before the incision. Many surgeons prefer to wait until the hip capsule is opened so specimens can be obtained that might produce accurate cultures before antibiotics are administered. Some surgeons have reported that because of JCAHO requirements they are being penalized because of that provision on the hospital side . We have had discussions with CMS and we are addressing that situation. The technical specification of PQRI are finalized and cannot be changed so the way to get around the problem in PQRI is to use a 1P modifier on measure #20 and document in the hospital record the reason for not administering the antibiotic one hour before the incision. We have written an official letter to Dr. Tom Valuk at CMS and he has promised to address the problem on the hospital side.
5. A suggestion by CMS is that you notify your patients that you are participating in PQRI. It can be used as a marketing effort to show that you are participating in a quality movement. A sign in your waiting room might be appropriate.

In summary, there are a number of reasons to participate in PQRI this year. The primary reason for not participating is if you must pay more to modify your practice management system than you might recover in a bonus. Even then, you would be learning how to report performance measures, a process that is likely to become mandatory in the future.

Please review all the material on this web site. If you have questions, you can send an email to PQRI@aaos.org and we will respond as quickly as possible.

Additional Information

• PQRI Initiative Overview and FAQs on the CMS web site
• 2008 PQRI Coding for Quality Handbook – CMS (275 page pdf; 1.4 mb; December 21, 2007)
• 2008 Measure Specifications Release Notes – CMS (14 page pdf;127 kb; December 21, 2007) Describes recent changes to measure specifications due to technical corrections.
• Listen to an Educational Webinar on the 2007 PQRI
  Presented by Susan Nedza, MD, Medical Officer at the Centers for Medicare and Medicaid Services (CMS) specifically for AAOS (May 2007).
• AAOS Now article: Clinical performance measures depend on physician input (June 2007)
• AAOS Now article: PQRI: A way to get more out of Medicare (May 2007)
• AAOS Now article: Getting your share of the CMS P4P 2007 bonus payments (January/February 2007)
• National Plan and Provider Enumeration System (NPPES)