Q: What is the status of the Physician Quality Reporting Initiative?
A: PQRI is a reporting program whereby eligible professionals report on a specific set of quality measures for services paid under the Medicare Physician Fee Schedule. An example of a quality measure in eye care is performing an optic nerve head evaluation on a patient with primary open-angle glaucoma. Currently, the program remains voluntary and you are not obligated to participate. Health and Human Services Secretary Michael Leavitt anticipates that by collecting data, providers can utilize the information to improve the quality of care for Medicare beneficiaries.
Q: Is there an incentive to participate?
A: Yes. The Tax Relief and Health Care Act of 2006 authorized a financial incentive for providers to participate in the program and earn a bonus payment for quality measures reported on services provided under traditional Part B plans for the final six months of 2007. The Medicare, Medicaid and SCHIP Extension Act of 2007 continued the program for 2008 and the Medicare Improvements for Patients and Providers Act (MIPPA) continues the program for 2009. The program does not apply to Medicare Advantage plans.
Q: Who is considered an eligible professional in eye care?
A: Eligible professionals are defined in the Social Security Act. Eye care providers include ophthalmologists, optometrists, osteopaths, physician assistants, nurse practitioners, anesthesiologists and CRNAs. (This list is not all-inclusive.)
All Medicare-enrolled professionals are eligible, participating or non-participating. No enrollment is needed to participate in the PQRI program. Eligible professionals begin by submitting appropriate quality-data codes on their claims.
Q: How is the bonus calculated?
A: Providers were eligible for a 1.5 percent bonus in 2008, and the bonus increases to 2 percent in 2009. The bonus applies to all Medicare Part B allowed charges (including the beneficiary deductible and co-payment), not just those services associated with quality measures.
Q: What quality measures applied to eye care providers in 2008?
A: Five measures applied. They were:
1. Primary open-angle glaucoma: optic nerve head evaluation.
2. Age-related macular degeneration: dilated macular examination.
3. Diabetic retinopathy: documentation of presence or absence of macular edema and level of severity of retinopathy.
4. Diabetic retinopathy: communication with the physician managing ongoing diabetes care.
5. Dilated eye exam in diabetic patient (new).
Q: How are these measures reported to Medicare?
A: Quality measures are reported with Category II codes (xxxxF). They are reported on the same claim as the patient diagnosis and service to which the quality-data code applies. For example, the quality measure for POAG, optic nerve head evaluation, 2027F, is reported when performed with the exam service (CPT E/M or eye code) and POAG ICD-9 code (i.e., 365.01, 365.10 etc.). This claim to Medicare requires two lines to report the office visit and the PQRI quality measure.
Q: How often must specific measures be reported for each qualifying patient?
A: The number of times that a particular measure must be performed and reported per eligible patient varies. The glaucoma example cited above must be reported once in the reporting period (calendar year). It is unnecessary to report it more than required. Nonetheless, you are not penalized for reporting it more frequently than needed.
Q: How many measures must be reported to secure the bonus?
A: It is recommended that you report on every applicable measure to achieve reporting thresholds. If no more than three measures apply to your practice, each measure must be reported for a minimum of 80 percent of the cases in which a measure was reportable. If four or more measures apply, at least three must be reported for a minimum of 80 percent of the cases in which a measure was reportable.
For example, let's use the glaucoma measure as one measure applicable to your practice. Every time you utilize the diagnosis of open-angle glaucoma as a primary diagnosis for the office visit, you must report the quality measure at least once on each of 80 out of every 100 patients in order to successfully report this measure. You must successfully report on at least three measures to secure the bonus.
Q: How are measures tracked to determine if the threshold is satisfied?
A: Measures are tracked and linked to an individual provider using the national provider identifier (NPI) on claims; the bonus payments are made to the holder of the taxpayer identification number (TIN).
Q: Could some providers in a group practice be successful and others not?
A: Yes. Because the measures are tracked by individual provider numbers, it is possible that one provider meets the requirements and another provider in the same group does not. The bonus check itself does not specify who was successful and who was not successful. As previously stated, it is written to the holder of the tax ID number.
Q: Is there a means to monitor potential success with reporting?
A: Unfortunately, no mechanism currently exists to determine if you are on track for a bonus payment. On completion of the analysis, a complex system exists to review your individual results by physician, but it's not available until the reporting period is over. No appeal rights exist if you disagree with the report.
Q: Did physicians receive bonus payments for their 2007 efforts?
A: Yes, in some cases. The Centers for Medicare & Medicaid Services reported on July 15, 2008 that more than $36 million in bonus payments would be paid out for the 2007 PQRI program. Regrettably, only 52 percent of those who participated achieved the necessary thresholds to receive the bonus. On average, individual physicians received bonuses of approximately $600 and group practices received $4,700.
Q: Will 2009 contain the same measures as the 2008 program?
A: No. There will most certainly be changes to the 2009 program. For additional information on the 2009 program, visit the CMS website at: cms.hhs.gov/pqri.
Q: Is the PQRI program linked to the 2009 e-prescribing bonus program?
A: No. The two programs are separate, as are the two bonuses. A similar reporting mechanism is expected for the e-prescribing program.
Q: What should I consider in deciding whether or not to participate?
A: Because the program functions on a calendar year, the earlier you begin the process, the easier it is to meet the requirements. Analyze your traditional Medicare Part B allowed charges to determine approximate financial value. There are costs associated with updating computer systems and route slips and training. This program may be a precursor to pay for performance and ease you into reporting on your services.
Ms. McCune is vice president of the Corcoran Consulting Group. Contact her at DMcCune@corco ranccg.com.
