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Published 5/1/2007
Robert H. Haralson III, MD, MBA

Facts and FAQs on the Physicians Quality Reporting Initiative

Reporting is relatively painless, with some long-term benefits

The Physicians Quality Reporting Initiative (PQRI), an extension of the Centers for Medicare and Medicaid Services’ (CMS) Physicians Voluntary Reporting Program, may actually result in payments to participants. What’s more, it offers a nonpunitive opportunity for orthopaedic practices to learn how to collect and report performance measures.

The facts on PQRI
The program runs from July 1 through December 31, 2007. Neither registration nor Medicare participation is required to participate in the PQRI. To qualify for a bonus, a physician must report at least three of the 74 performance measures for 80 percent of their eligible patients.

Four performance measures are easily applicable to orthopaedic surgical practices:

  • An order for a prophylactic antibiotic within one hour of one of the listed surgical procedures (# 20)
  • Use of a first or second generation cephalosporin unless another antibiotic was indicated (# 21)
  • An order to discontinue the antibiotic within 24 hours of the procedure (#22)
  • Administration of prophylactic thromboembolic medication or mechanical prevention techniques (#23)

The nonsurgical measures, particularly for osteoporosis, that are part of the program include the following:

  • Screening for osteoporosis (# 39)
  • Management of osteoporosis following fracture (# 40)
  • Pharmacologic treatment of osteoporosis (# 41)
  • Counseling for vitamin D, calcium intake, and exercise (# 42)

Recently, CMS published the technical specifications of reporting on the CMS Web site (www.cms.hhs.gov/pqri). You can also access the lists through the AAOS Web site (www.aaos.org/research).

Reporting performance measures
Under the PQRI, you would append a common procedure terminology (CPT) level II code or a G-code to the CMS 1500 reporting form for the procedure. The technical specifications detail which CPT or G-code should be used.

A detailed review of the measures indicates that reporting may not be difficult. For example, the description of measure #20—Perioperative Care: Timing of Antibiotic Prophylaxis – Ordering Physician—reads as follows:

    Percentage of surgical patients aged 18 years and older undergoing procedures with the indications for prophylactic parenteral antibiotic, who have an order [emphasis added] for prophylactic antibiotic to be given within one hour (if fluoroquin or vancomycin, two hours), prior to the surgical incision (or start of the procedure when no incision is required)

The measure further states that the order can be written, oral, or part of routine orders. For reporting purposes, you don’t even have to be sure that the prophylactic antibiotic was administered, only that there was an order for it.

This particular measure is reported with CPT level II code 4047F when an order for the antibiotic is documented, or with code 4048F when there is documentation that the antibiotic was actually administered. If an order for antibiotic was not given for medical reasons, modifier 1P is appended to the code. If the order was not given for some unspecified reason, modifier 8P is used. In either case, you will receive credit for reporting the measure.

Likewise, for measure # 21—Selection of Prophylactic Antibiotic–First or Second Generation Cephalosporin—you report the fact that there was an order for the antibiotic, not necessarily that it was actually administered. Use code 4041F to report the measure, with modifier 1P if you choose, for any reason, to use another antibiotic.

The same situation exists for measure # 22—Discontinuation of Prophylactic Antibiotics. Again, the requirement is that there is an order, written or oral, that the antibiotic is to be discontinued within 24 hours of surgical end time.

The list of suitable agents included in the technical specifications for measure # 23—Venous Thromboembolic (VTE) Prophylaxis (When Indicated in ALL Patients)—includes all commonly used agents, except aspirin, as well as mechanical devices. No dosage or laboratory levels are described; the requirement is only that the prophylaxis was ordered. This measure has a shorter list of procedures because after many procedures in which antibiotics are indicated, the patient is encouraged to walk immediately after surgery and thromboembolic prophylaxis is not indicated.

Getting your bonus—and your NPI
Physicians who report the required number of measures are eligible for a bonus of up to 1.5 percent of their total Medicare charges (not just the charges for reported procedures) for that period. In some cases, a cap may apply. This cap cannot be determined until the end of the reporting period and applies when a physician reports few instances of quality measure data.

The bonus will be calculated based on the physician’s National Provider Identifier (NPI), but the check will be payable to the appropriate pay number. Practices that have multiple physicians using the same pay number will need to decide how to distribute the money to the individual physicians. The practice will be able to obtain a report showing the reporting by each individual physician, so making the distribution calculation should not be difficult. If you don’t yet have your NPI, see the article on page 35 for information on obtaining one.

The FAQs on PQRI
The PQRI Web site includes several “Frequently Asked Questions (FAQs),” and I’ve frequently been asked questions as well. Following are some commonly asked questions and answers:

I am a reconstructive surgeon who also takes emergency room (ER)calls. If I choose to report on the four orthopaedic measures (#20-23), do I have to report them for the ER trauma and fracture cases as well as my joint reconstruction cases?
Yes. If you choose to report on those four measures, you must report them for all eligible procedures.

How much will it cost to collect the data compared to what I might receive as a bonus?
There are varying estimates for this, but I can imagine a scenario in which it would cost very little. The AAOS is developing a worksheet that will include all reportable procedures with their applicable CPT level II or G-codes. A billing clerk could be instructed to use this worksheet and add the appropriate CPT or G-codes to the CMS 1500 form used to report the procedure. This makes reporting automatic and costs almost nothing. The documentation will be in the hospital record; although you may need to ensure that the documentation is properly included in the record, this should be a minimal expense.

Why should I bother to participate?
In addition to the bonus, you will reap other benefits by participating in the PQRI program. There is little doubt that PQRI will be expanded in 2008. By participating in 2007, you have a chance to practice on a voluntary reporting process without penalties for not getting it right.

Robert H. Haralson III, MD, MBA, is the AAOS Medical Director. He can be reached at (847) 384-4040 or haralson@aaos.org