Oncology & Hematology Coding Alert

The Physician Quality Reporting Initiative (PQRI) has already begun for 2008. To be sure you-re on the right track, you need to know what this means for you as a coder and how PQRI can affect your bottom line. We give you the information you need to avoid the potential reporting pitfalls.

Your physicians don't need to enroll or file intent to participate in the PQRI. They can participate by reporting the appropriate quality data codes on claims submitted to your Medicare claims processing contractor. These measures should always be reported with the appropriate ICD-9 and CPT codes. Refer to "We Bring You the 2008 PQRI in a Nutshell" following this article for more details on this. For more information, the PQRI coding handbook is online at http://www.cms.hhs.gov/PQRI/Downloads/2008PQRICodingforQualityHandbook.pdf.

Watch for: "The PQRI code will only be counted and recognized when it is billed on the same claim with the specified CPT codes," says Joyce Matola, billing manager for the Center for Cancer and Hematologic Disease in Cherry Hill, N.J. "All PQRI Category II codes for the PQRI measures must be reported on the same claim with the CPT codes as outlined in the Coding Specifications." You-ll be able to find these codes and much more on the CMS Web Site at http://www.cms.hhs.gov/PQRI/.

There are several PQRI measures that apply to oncology and hematology. These include the following:

- 67 -- Baseline cytogenic testing performed on bone marrow

- 68 -- Documentation of iron stores in patients receiving erythropoietin therapy

- 69 -- Treatment with biophosphonates

- 70 -- Baseline flow cytometry

- 71 -- Hormonal therapy for Stage IC-III ER/PR positive breast cancer

- 72 -- Chemotherapy for Stage III colon cancer patients

- 73 -- Plan for chemotherapy documented before chemotherapy administered

- 74 -- Radiation therapy recommended for invasive breast cancer patients who have undergone breast conserving surgery

- 99 -- Breast cancer patients who have a pT and pN category and histologic grade for their cancer

- 100 -- Colorectal cancer patients who have a pT and pN category and histologic grade for their cancer

- 101 -- Appropriate initial evaluation of patients with prostate cancer

- 102 -- Inappropriate use of bone scan for staging low-risk prostate cancer patients

- 103 -- Review of treatment options in patients with clinically localized prostate cancer

- 104 -- Adjuvant hormonal therapy for high-risk prostate cancer patients

- 105 -- Three-dimensional radiotherapy for patients with prostate cancer.

You only have to report on three measures per claim at least 80 percent of the time when that measure applies to any patient seen by the physician. When there are four or more applicable measures, you need to meet the 80 percent threshold on at least three of the measures reported.

Important reminder: Matola notes that all PQRI claims must be reported with the provider's National Provider Identifier number.

You have to learn to use four new modifiers to explain the specific action involved with the PQRI measure you-ve coded. These modifiers are 1P (Exclusion modifier due to medical reasons), 2P (Exclusion modifier due to patient reasons), 3P (Exclusion modifier due to system reasons), and 8P (Reporting modifier -- action not performed, reason not otherwise specified).

One thing to remember is that you use these modifiers with PQRI Category II codes -- not with G codes.

These modifiers "are the most difficult piece to understand," says Kristie Risley with Sterling Healthcare in Durham, N.C.

Modifiers you find in the PQRI handbook can vary depending on which measure you-re coding for.

Here's an example. If the oncologist didn't prescribe intravenous biophosphonate therapy in connection with treatment for multiple myeloma (not in remission) for medical, patient or system reasons, you-ll add one of these modifiers to 4100F (Biophosphonate therapy, intravenous, ordered or received [HEM]):

- 1P -- Documentation of medical reason(s) for not prescribing biophosphonate therapy

- 2P -- Documentation of patient reason(s) for not prescribing biophosphonate therapy.

If the physician didn't prescribe biophosphonate therapy for an unknown reason, you-ll add modifier 8P (Biophosphonate therapy was not prescribed, reason not otherwise specified) to 4100F.

In that case, you would also send the chart back to the physician asking for more information to limit the use of modifier 8P, according to Sandra Pinckney, CPC, coder in Grand Rapids, Mich. Using 8P indicates that the physician is not taking credit for that service.

Suppose your physician provides a level-three office consult to a 65-year-old patient with invasive breast cancer, which began in the central portion of the breast. The physician documents her recommendation that the patient begin radiation therapy within the next six months.

What to do: You should report 99243 (Office consultation for a new or established patient ...) for the consult. For the diagnosis, report 174.1 (Malignant neoplasm of female breast; central portion). In the PQRI coding handbook, you see that you should report G8379 (Documentation of radiation therapy recommended within 12 months of first office visit) as the PQRI code.

If you-re not already reporting for PQRI, there is definitely a financial incentive for your office to get involved now.

If your oncologist is eligible, and if you successfully report from the designated set of quality measures, you can receive reimbursement for up to 1.5 percent of all of your Medicare billings -- the same rate you saw in 2007 -- during that period.

Good news: "We recognize that quality extends beyond the physicians," said CMS- Susan Nedza, MD, MBA, FACEP, during a CMS PQRI national provider call. Nedza encouraged all eligible personnel to actively participate in PQRI.

To receive the bonus, your providers will have to report on up to three measures per claim for covered services payable under the Medicare Physician Fee Schedule. The bonus will apply to all allowable charges, including deductibles and copayments. Bonus calculations won't include physician laboratory or physician-administered drug charges, and there will be no beneficiary co-insurance requirement for quality measures you report.

There's a cap that might reduce your bonus amount if your doctor meets the 80 percent requirement but doesn't report measures very often. The cap is designed to reduce the bonus for providers who meet the requirements but don't report on quality measures often enough. That way, if you report on quality measures only a few times, you won't get the full 1.5 percent bonus. There won't be an appeal process for physicians to question their bonus payments.

Rest easier: For the time being, the PQRI isn't based on performance. This means that you-ll get paid regardless of whether your doctor actually performed the measures you-re reporting on.

The 2008 PQRI reporting period runs from Jan. 1 to Dec. 31, 2008.

If your office reported for 2007 PQRI, you can still report 2007 quality-data codes on claims with services dated up to Dec. 31, 2007. This is valid through Feb. 29, 2008.

If you report 2008 measures successfully, you-ll receive your 2008 incentives in mid-2009.

Tip: For more information on PQRI, visit the CMS Web Site at http://www.cms.hhs.gov/pqri/.

You can also find a listing of the quality measures on the AMA Web site at http://www.ama-assn.org/ama/pub/category/17493.html. This includes descriptions of each measure, coding specifications and a data collection sheet to help you with documentation.