2010 PQRI Moves Forward

By Julie Orton Van, CPC, CPC-P, CEMC, CGSC, COBGC

Each year, the Centers for Medicare & Medicaid Services (CMS) implements the Physicians Quality Reporting Initiative (PQRI) through a rulemaking process published in the Federal Register. In general, CMS has responded positively to provider feedback and continues to provide educational opportunities and implementation resources to encourage better participation. They have endeavored each year to address system and reporting difficulties.

For 2010, PQRI includes several key changes, including:

CPB : Online Medical Billing Course

More Quality Measures 

For 2010, CMS adds 30 new, individual PQRI measures and six measures groups on which individual eligible professionals (EPs) may report. The added individual measures are identified in table 13 (pages 93 and 94) of the Nov. 25, 2009 Federal Register. The six new measures groups include:

  • Coronary Artery Disease (CAD)
  • Heart Failure
  • Ischemic Vascular Disease (IVD)
  • Hepatitis C
  • Human Immunodeficiency Virus (HIV)/Acquired Immune Deficiency Syndrome (AIDS)
  • Community Acquired Pneumonia (CAP)

A complete listing of 2010 measures groups may be found in the Nov. 25, 2009 Federal Register, tables 15-27 (pages 97-103).

Group Practice Reporting

Group practices that satisfactorily report data on PQRI measures are eligible to earn a PQRI incentive payment equal to 2 percent of the group practice’s total estimated Medicare Physician Fee Schedule (MPFS) allowed charges for covered professional services furnished during the 2010 reporting period. For instance, if the group practice meeting the participation criteria successfully reports total estimated allowed MPFS charges of $940,000, the practice’s total earned incentive amount would be $18,800.

To participate in the 2010 PQRI group practice reporting option (GPRO), a group practice—defined as “consisting of 200 or more individual EPs who have reassigned their billing rights to the TIN [Tax Identification Number]”—must have submitted a self-nomination letter to CMS prior to Jan. 31, and must have been selected to participate in the 2010 PQRI GPRO.

Each group practice selected to participate in the 2010 PQRI GPRO is required to report 26 quality measures, from five measures groups unique to the GPRO:

1. Diabetes Mellitus (DM) Disease Module (eight measures)

2. Heart Failure (HF) Disease Module (seven measures)

3. Coronary Artery Disease (CAD) Disease Module (four measures)

4. Hypertension (HTN) Disease Module (three measures)

5. Preventive (Prev) Care Measures (four measures, individually sampled)

The reporting mechanism is a pre-populated data collection tool CMS provides. Group practices must complete the tool for the first 411 consecutively-ranked and assigned patients in the order in which they appear in the group’s sample for each disease module or preventive care measure.

As in past years, EPs who are reporting as individuals do not need to sign up or pre-register to participate in the PQRI. To participate, EPs may choose to report information on individual PQRI quality measures or measures groups to CMS:

(1) On their Medicare Part B claims,

(2) Through a qualified PQRI registry, or

(3) Via a qualified electronic health record (EHR) product.

Individual EPs who meet the criteria for satisfactory submission of PQRI quality measures data using any of these reporting mechanisms for services furnished during a 2010 PQRI reporting period will qualify to earn a PQRI incentive payment equal to 2 percent of their total estimated MPFS-allowed charges for covered professional services furnished during the reporting period. For example, if Dr. Doe reports a sufficient number of measures, reported at 80 percent, and his total estimated allowed MPFS charges are $80,000, his total earned incentive amount would be $1,600.

An important note: An individual EP who is a member of a group practice selected to participate in the PQRI GPRO is not eligible to earn a separate, individual PQRI incentive payment. When a group practice (TIN) is selected to participate in the GPRO, this is the only PQRI reporting method available to the group and all individual NPIs who bill Medicare under the group’s TIN.

EHR Reporting Mechanism

In addition to the claims-based and registry-based reporting mechanisms, CMS will accept PQRI quality measures data extracted from a qualified EHR product on 10 individual PQRI measures, and will—for the first time—allow EPs to count their submission of EHR-based measures toward their eligibility for a PQRI incentive payment.

The final rule provides that EPs who satisfactorily report data on at least three of the 10 EHR-based individual PQRI measures are eligible for an incentive payment. In previous years, EHR-based measure submission has been on a voluntary or pilot basis, and has not counted towards an EP’s eligibility for an incentive payment. The addition of an EHR-based reporting mechanism is meant to promote the adoption and use of EHRs, and to provide EPs and CMS with experience on EHR-based quality reporting.

To qualify for PQRI reporting eligibility, a registry or EHR product must go through a self-nomination and vetting process (if they are new to PQRI registry reporting), or must notify CMS of their desire to continue PQRI data submission in 2010 (if they were qualified in 2009 and successfully submitted their users’ quality data). Some EHRs also can report the electronic prescribing measure. In addition to capturing the required data elements for the measure calculation, these qualified EHR products also can transmit the required information in the requested file format.

See the Resource Tips at the end of this article for a list of qualified registries for CMS 2010 PQRI reporting.

New, Six-month Reporting Period for Individual Measures

A six-month period for claims-based reporting of individual measures begins July 1. In prior years, the six-month reporting period was available only for measures group reporting or for registry-based reporting.

Success Depends on Meeting the Threshold

PQRI incentive payments are issued separately as a single consolidated incentive payment in the following year. Before an EP can receive an incentive payment for reporting 2010 quality data, however, he or she must meet specific reporting thresholds that depend on the reporting period and option used.

For those EPs who use the claims-based reporting method of individual measure(s), CMS determines whether the provider reported quality data for measures satisfactorily as a general validation. After CMS has determined that the provider submitted valid quality data codes (QDCs), the agency determines if the EP should have submitted QDCs for additional measures using a two-step Measure-Applicability Validation (MAV) process.

For example, if the provider submits quality data for Measure 1. Diabetes Mellitus: Hemoglobin A1c Poor Control in Diabetes Mellitus, CMS will assume other measures related to care of patients with chronic diabetes mellitus are applicable to that practice.

Additional information on the MAV process can be found on the Analysis and Payment page of the PQRI section of the CMS website at www.cms.hhs.gov/PQRI.

PQRI Feedback Reports

Each year, the PQRI incentive payment and the PQRI feedback report are issued through separate processes. PQRI feedback report availability is not based on whether an incentive payment was earned. Feedback reports will be available for every TIN under which at least one eligible professional (identified by his or her NPI) submitting PFS claims reported at least one valid PQRI measure at least once during the reporting period. PQRI participants will not receive claim-level details in the feedback reports.

Following the distribution of 2010 incentive payments, CMS will (as required by the Medicare Improvements for Patients and Providers Act (MIPPA)) post on its website the names of EPs and group practices that satisfactorily report quality measures.

PQRI is a good way to maximize revenue while adding to data important for improved patient care. Although the group practice deadline has passed for 2010, individual EPs are still able to participate and earn payments for this year. And it’s not too late for any practice to begin planning for 2011.

Julie Orton Van, CPC, CPC-P, CEMC, CGSC, COBGC, works at Ingenix as a product manager. She has more than 25 years experience in the health care industry, including physician office management, home health and hospice, managed care, laboratory services, physician and facility contracting, benefits administration, and claims payment, clinical information systems. Prior to Ingenix, she was a systems analyst for a fully integrated electronic medical record (EMR) at a large teaching hospital and health care system. She can be reached at Julie.Van@Ingenix.com.

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