Pathology/Lab Coding Alert

Use alternative reporting period to prepare for 2009.

If you think that pathology measures qualify for the July 1 start date of Medicare's 2008 Physician Quality Reporting Initiative (PQRI) -- think again.

-I-ve heard from pathologists who-ve been led to believe that Medicare's new -alternative reporting period- rule means they could start participating in PQRI as of July 1, 2008,- says Dennis Padget, MBA, CPA, FHFMA, president of DLPadget Enterprises Inc. in Simpsonville, Ky. and publisher of the Pathology Service Coding Handbook.

-That's not true. The July 1 to Dec. 31 alternative reporting period only applies to physicians who are eligible to report on at least one of four new measure groups,- Padget explains.

The measure groups pertain to diabetes, end stage renal disease, chronic kidney disease, and preventive care -- none of which impacts pathologists, according to Padget.

Bottom line: -The 2008 PQRI reporting period for pathologists participating in the breast and colorectal cancer quality measures remains Jan. 1 through Dec. 31, without exception,- Padget says.

Know Medicare -Alternative Reporting Period- Rules

You have to read the fine print to understand Medicare's PQRI 2008 alternative July 1��"Dec. 31 reporting period.

Although CMS stated in an open letter to physicians in June that -it is not too late for those who have not yet started reporting quality data to begin participation for 2008,- such general statements don't tell the whole story.

Know this: CMS- Change Request 6104 states that the alternative reporting period does not apply to -individual PQRI measures using the claims-based method of reporting,- but applies only to -measures groups.- You can access CR6104 on the Internet at www.cms.hhs.gov/transmittals/downloads/R355OTN.pdf.

In other words: The alternative reporting period rule doesn't apply when pathologists report individual measures based on claims reporting, according to Padget.

PQRI Goal: Get Paid for Value, Not Volume

PQRI is a voluntary quality reporting system that Congress initially authorized by the 2006 Tax Relief and Health Care Act, and CMS implemented in 2007. The program allows eligible professionals who satisfactorily report on the quality of services furnished to Medicare Part B Fee-for-Service beneficiaries to receive a financial incentive.

CMS views PQRI as an important step toward a transformation to purchasing services based on value rather than just volume, according to Michael Rapp, MD, JD, FACEP, director of the quality measurement and health assessment group in the CMS office of clinical standards and quality in an open letter to physicians.

Pathologists can now participate: Although no quality measures applied to pathology in 2007, CMS implemented two performance standards that pathologists can report in 2008. -Even if you-re sitting out the voluntary program this year, you need to get ready for a potentially expanding list of quality measures that could impact your bottom line in the future,- Padget says.
Pathologists can expect the same breast and colorectal cancer PQRI measures for 2009, according to Padget. And although you can't use the alternative reporting period to earn bonus pay this year, you can use it as a wake-up call to ramp up your PQRI reporting for next year.

How it works: A participating pathologist must demonstrate that he reported appropriate quality measures for 80 percent of eligible cases during the reporting period Jan.1--"Dec. 31. If so, that pathologist will receive a 1.5 percent bonus for his total Medicare allowed charges, not just the PQRI-eligible cases. That means you-ll get an additional 1.5 percent pay for all types of pathology specimens plus special stain and other ancillary pathology services.

Don't miss: -Medicare calculates the bonus based on allowed charges per individual reporting-physician NPI, not at the group or lab level,- Padget says

Know These 2 Pathology Measures

Pathologists will find two PQRI measures in 2008 that apply to their services for breast cancer and colorectal cancer, as follows:

Breast cancer specimen reporting: This quality measure evaluates the percentage of breast cancer resection pathology reports that include the pT category (primary tumor), the pN category (regional lymph nodes), and the histologic grade.

Colorectal cancer specimen reporting: Similar to the breast cancer quality measure, this measure looks at the percentage of colon and rectum cancer resection pathology reports that include the pT category (primary tumor), the pN category (regional lymph nodes), and the histologic grade.

Do this: Report compliance with both measures using new CPT Category II code 3260F (pT category [primary tumor], pN category [regional lymph nodes], and histologic grade documented in pathology report). To get the bonus, you must report PQRI quality code 3260F for at least 80 percent of all qualifying breast and colorectal cancer cases signed out during the year.
Don't forget ICD-9 and CPT: You shouldn't report 3260F alone. -Medicare will only recognize and count the PQRI code when you bill it on the same claim with an eligible CPT code and a qualifying ICD-9 code,- says Joyce Matola, billing manager for the Center for Cancer and Hematologic Disease in Cherry Hill, N.J.

For breast cancer, qualifying cases involve those specimens that you bill as one of the following:

- 88307 -- Level V -- Surgical pathology, gross and microscopic examination; breast, excision of lesion, requiring microscopic evaluation of surgical margins;  breast, mastectomy --" partial/simple
- 88309 -- Level VI -- Surgical pathology, gross and microscopic examination; breast, mastectomy --" with regional lymph nodes.

To qualify for PQRI, the breast case also must involve one of these ICD-9 codes: 174.0-174.9 (Malignant neoplasm of female breast) or 175.0-175.9 (Malignant neoplasm of male breast).

For colon cancer, qualifying cases involve those specimens that you bill as 88309 (- colon, segmental resection for tumor; colon, total resection).

To qualify for PQRI, the colon cancer case must involve one of these ICD-9 codes:

- 153.0-153.9 -- Malignant neoplasm of colon
- 154.0 -- Malignant neoplasm of rectosigmoid junction
- 154.1 -- Malignant neoplasm of rectum
- 154.8 -- Malignant neoplasm of rectum, rectosigmoid junction, and anus; other.

You get the bonus for reporting, not performing: Even if the pathologist doesn't perform one of the measures, you should still report 3260F for an eligible case under current CMS rules. You-ll have to use an appropriate PQRI modifier, such as 1P (Performance measure exclusion modifier due to medical reasons) or 8P (Performance measure reporting modifier -- action not performed, reason not otherwise specified) to indicate that you did not perform the measure.