Internal Medicine Coding Alert

Published on Mon Jan 28, 2008 PDF

Most internists can easily report on diabetes patients.

Internal medicine providers interested in a year-end bonus from Medicare can choose to report in the Physician Quality Reporting Initiative (PQRI) again in 2009 ��" this time at a higher rate of return.

The basics: In 2008, the PQRI bonus was 1.5 percent for practices that met the measures. In 2009, PQRI is scheduled to pay a 2 percent bonus, relayed Alice Reybitz, RN, BA, CPC, CPC-H, during her session on PQRI at The Coding Institute's multispecialty conference in Orlando, Fla. Check out these PQRI basics as a first step toward participating in this program.

The first step in PQRI participation is focusing your reporting on measures your practice will often meet. According to CMS, the 2009 PQRI includes 153 reporting measures. There is an "endless" amount of PQRI measures that might apply to your practice, according to Eileen Lane, CPC, PCS, senior compliance auditor with Harvard Medical Faculty Group at Beth Israel Deaconess Medical Center. It all depends on your internist's area of expertise.

"Some internists specialize in cardiology, so there are measures that would apply to them; others specialize in pulmonology, etc.," Lane explains.

There are, however, a few measures that most internists should be able to report regardless of specialty:

• 1 --" Diabetes Mellitus: Hemoglobin A1c Poor Control in Diabetes Mellitus

• 2 --" Diabetes Mellitus: Low Density Lipoprotein (LDL-C) Control in Diabetes Mellitus

• 3 --" Diabetes Mellitus: High Blood Pressure Control in Diabetes Mellitus

• 39 --" Screening or Therapy for Osteoporosis for Women Aged 65 Years and Older

• 56 --" Community-Acquired Pneumonia (CAP): Vital Signs

• 92 --" Acute Otitis Externa (AOE): Pain Assessment

• 114 --" Preventive Care and Screening: Inquiry Regarding Tobacco Use.

Note: This is not a comprehensive list, and these measures might not be the easiest ones for your practice to meet. Check out the list of PQRI measures at www.cms.hhs.gov/PQRI/Downloads/2009PQRIMeasuresList.pdf before deciding on which ones to report. Use this online resource to "decide what works for your practice, and what you will need to do to meet the measures," recommends Reybitz.

To qualify for PQRI, you need to report on only three measures in at least 80 percent of cases to qualify; internists who meet this threshold will get a 2 percent bonus on all total allowed charges for covered services.

You will, however, need to do a little extra coding for PQRI participation, relays Caral Edelberg, CPC, CCS-P, CHC, president of Medical Management Resources for TeamHealth in Jacksonville, Fla. "There are specific PQRI quality-data codes associated with each of the PQRI measures," she says.

The PQRI quality-data codes are CPT Category II codes, located in the back of CPT 2009. Also, be sure to note Appendix H in CPT 2009, which lists all the performance measures along with the Category II codes you should report for each measure.

Follow these steps on each of your claims to increase PQRI reporting success:

• Review documentation to determine if treatment is consistent with the PQRI measure.

• Assign the CPT and ICD-9 codes as you would normally for the claim.

• Check to make sure your ICD-9 and CPT codes line up with the measure's requirements.

• Assign the appropriate Category II code, and any modifiers that you might need.

Consider this example from Lane, which illustrates proper reporting on measure 92:

A 67-year-old established female Medicare patient presents with severe ear pain. The internist performs a level-three E/M, assesses the patient's periauricular pain, and diagnoses "diffused otitis externa, acute."

Since the physician documented that she checked the patient's periauricular pain and met age requirements, this encounter counts toward PQRI. On the claim, you would report the following:

• 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: an expanded problem focused history; an expanded problem focused examination; and medical decision making of low complexity) for the E/M

• 380.10 (Infective otitis externa, unspecified) appended to 99213 to represent the patient's condition

• 1116F (Auricular or periauricular pain assessed [AOE]) for PQRI purposes.

If a patient's condition mirrors one of the PQRI measures, but the physician does not meet all the treatment requirements during the visit, you can still report the encounter to PQRI. Just remember to append a P modifier to the Category II code, says Lane.

These modifiers, which explain to Medicare why the physician did not meet the PQRI measure, are:

• 1P --" Measure not met for medical reasons

• 2P --" Patient declined treatment associated with measure

• 3P --" Measure not met for system reasons

• 8P --" Measure not met, reason not specified.

Example: Let's say a 69-year-old Medicare patient presents to the internist with syncope. PQRI measure 55 calls for the physician to perform a 12-lead electrocardiogram (EKG or ECG) on all patients over 60 with syncope to qualify for PQRI. If your physician did not perform an ECG at that visit, you would still use a PQRI code, but you would also need a modifier to indicate the ECG was not performed.

So if notes indicate a level-three E/M service, and that the patient refused the ECG for financial reasons, you would report the following:

• 99213 for the E/M

• 780.2 (Syncope and collapse) for the syncope

• 3120F (12-lead ECG performed [EM]) for the PQRI measure

• modifier 2P appended to 3120F to show why the EKG was not performed.

Wondering how to get started on PQRI? Go to www.cms.hhs.gov/PQRI and familiarize yourself with the guidelines for PQRI reporting. You might want to bookmark this site, because it contains an overview of the program and links to resources you might find useful, such as the "PQRI Tool Kit."

Best bet: Refer back to this Web site when you have questions about PQRI; it is the definitive source of PQRI information.