1. The 2009 Physician Quality Reporting Initiative (PQRI) and the Electronic Prescribing (E-Prescribing) Incentive Program
Sylvia W. Publ, MBA, RHIA Consortium for Quality Improvement
and S&C Operations, CQISCO
December 17, 2008

2. Disclaimers
This presentation was current at the time it was published or uploaded onto the web. Medicare policy changes frequently so links to the source documents have been provided within the document for your reference.
This presentation was prepared as a tool to assist providers and is not intended to grant rights or impose obligations. Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services. The Centers for Medicare & Medicaid Services (CMS) employees, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this guide. This publication is a general summary that explains certain aspects of the Medicare Program, but is not a legal document. The official Medicare Program provisions are contained in the relevant laws, regulations, and rulings.
CPT only copyright 2008 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS\DFARS Restrictions Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

3. Overview Value-Based Purchasing and the PQRI PQRI Introduction
2009 PQRI & E-Prescribing Incentive Programs
PQRI Reporting: measures & codes Implementing PQRI
Resources
Place in context, where CMS is going; PQRI is designed to help Medicare develop reimbursement and policies consistent with VBP
About PQRI; the measures, the coding,
How you can get started

4. Value-Based Purchasing and PQRI
Key mechanism for transforming Medicare from passive payer to active purchaser.
Current Medicare Physician Fee Schedule is based on quantity and resources consumed, NOT quality or value of services.
Value = Quality / Cost
Incentives can encourage higher quality and avoidance of unnecessary costs to enhance the value of care.
VBP reflects policy concern about both cost and quality of care.
Medicare is largest purchaser of health care in the world, 12 million beneficiaries, expect expanded growth as population ages
In addition to the expected growth, concern about the sustainability of financing
In past 30 yrs Medicare spending has risen average of 9.3% considerably higher than the GPD 6.5%
Currently CMS spends $1b per day in Medicare
- IOM Crossing Quality Chasm 2001 highlighted the significant gaps in what we know is good care, and what actually gets delivered. Know beneficiaries do not always receive the care they need, that the quality of the care is not always the highest, and that there is significant geographic variation in the amount of services beneficiaries receive that is not necessarily related to outcomes, may expose them to higher risks, additional costs.
- Historically, Medicare reimburses for services as long as claims submitted appropriately according to administrative and policy regulations, regardless of quality of services, regardless of whether the services were appropriate to the patient or whether they led to improved outcomes.
- Policy makers are asking, “Are taxpayers getting good return for the dollars we are spending?”
Slide: As a result, CMS changing its culture and practice. We see Value-based purchasing as key mechanism to transform Medicare from Current payment system rewards quantity not quality or outcomes
Believe that incentives can encourage higher quality, avoid unnecessary costs – thus enhancing the value of care.

5. PQRI Legislative Background
TRHCA – Tax Relief & Health Care Act, 2006
Established 2007 PQRI, 7/1-12/31/07, authorized 1.5% incentive subject to a cap, claims-based reporting by eligible professionals (EPs) of up to 3 individual applicable measures for 80% of eligible cases
MMSEA - Medicare, Medicaid, and SCHIP Extension Act of 2007
Authorized 2008 PQRI, 1.5% incentive, eliminated cap Incentive
Required alternative reporting periods and alternative reporting criteria for 2008 and 2009
Requires alternative reporting for measures groups and for registry-based reporting
MIPPA - Medicare Improvements for Patients and Providers Act
Section 131: 2009 PQRI
Authorized PQRI 2009 raised incentive to 2%, adds qualified audiologists as eligible professionals, no effect on 2007 or 2008 incentive payments
Requires CMS to post on our web site names of EPs who satisfactorily report quality measures for 2009 PQRI
Section 132: e-Prescribing Incentive Program
Authorized separate 2% incentive payment to EPs who successfully use a qualified eprescribing system
eRx measure removed from 2009 PQRI --separately posted measure specifications.
The Secretary has the authority to update the codes of the electronic prescribing measure in the future.
Requires names of eligible professionals who are successful e-prescribers be posted on the CMS web site

6. Focus on Quality & Improvement
PQRI reporting focuses attention on quality of care.
Foundation is evidence-based measures developed by professionals.
Reporting data for quality measurement is rewarded with financial incentive.
Measurement enables improvements in care.
Reporting is the first step toward pay for performance.
Measures address various aspects of quality care
Prevention
Chronic Care Management
Acute Episode of Care Management
Procedural Related Care
Resource Utilization
Care Coordination
All measures developed by provider community; specialty societies and consumer groups; NQF, AQA (Alliance AAFP, ACP, AHRQ, AHIP)
All have good clinical rationale, reflect good measurement science, and are evidence-based

7. PQRI : Eligible Professionals
Physicians
MD/DO
Podiatrist
Optometrist
Oral Surgeon
Dentist
Chiropractor
Therapists
Physical Therapist
Occupational Therapist
Qualified Speech-Language Pathologist
Practitioners
Physician Assistant
Nurse Practitioner
Clinical Nurse
Specialist
Certified Registered Nurse
Anesthetist
Certified Nurse Midwife
Clinical Social Worker
Clinical Psychologist
Registered Dietician
Nutrition Professional
Audiologist
While called PQRI, somewhat misleading, open to other members of the health care team that are reimbursed under FFS Physician part B schedule.

8. 2009 PQRI Quality Measures 153 PQRI quality measures for 2009
Includes 101 measures from the 2008 PQRI and 52 new measures
E-prescribing measure (Measure #125) removed, as required by MIPPA as a separate program
18 measures reportable only through registries
By December 31, 2008, measure specifications will be available at:

9. 2009 PQRI Measures Groups 7 measures groups:
Diabetes Mellitus
Chronic Kidney Disease
Preventive Care
Coronary Artery Bypass Graft (CABG) (new)
Rheumatoid Arthritis (new)
Perioperative Care (new)
Back Pain* (new)
* Measures in this measures groups are reportable only as a measures group, not as individual measures
ESRD measure group removed for 2009

10. 2009 PQRI Reporting Periods
Reporting period: January 1, 2009 – December 31, 2009
2 reporting periods for reporting measures groups and registry-based reporting:
January 1, 2009 – December 31, 2009
July 1, 2009 – December 31, 2009

11. 2009 PQRI Satisfactory Reporting Options
Criteria for claims-based submission of individual measures (1 option):
Reporting period: January 1, 2009 – December 31, 2009
3 PQRI measures or 1-2 measures if < 3 apply*
80% of applicable Medicare Part B FFS patient claims for 1-3 measures
* If < 3 measures, measures are subject to measure applicability validation (MAV)

12. 2009 PQRI Satisfactory Reporting Options (ctd.)
Criteria for registry-based reporting of individual measures (2 options):
Reporting period: January 1, 2009 – December 31, 2009
≥ 3 PQRI measures
80% of applicable Medicare Part B FFS patient claims for ≥ 3 measures
Reporting period: July 1, 2009 – December 31, 2009

13. 2009 PQRI Satisfactory Reporting Options (ctd.)
Criteria for measures groups (6 options: 3 for claims-based submission and 3 for registry-based reporting):
Reporting period: January 1, 2009 – December 31, 2009
30 consecutive patients for 1 measures group OR
80% of applicable Medicare Part B FFS patient claims for 1 measures group, with a minimum of 30 applicable patients
Reporting period: July 1, 2009 – December 31, 2009
80% of applicable Medicare Part B FFS patient claims for 1 measures group, with a minimum of 15 applicable patients
Criteria for claims-based submission of measures groups identical to criteria for registry-based reporting of measures groups except only Medicare Part B FFS patients can be included in consecutive patient sample for claims-based submission of measures groups

14. Measure Applicability Validation
Satisfactorily Report ≥ 80% on ≥ 3 Measures
Not Subject to MAV
Yes No
Did EP report at least 1 measure included in a MAV Clinically Related Cluster?
Eligible for Incentive Payment
Satisfactorily Report ≥ 80% on < 3 Measures
Subject to MAV
Step 1 - Clinical Relation Test:
Did EP report number eligible claims below threshold < (30 pts)?
Step 2 - Minimum Threshold Test:
Did EP report number eligible claims above threshold ≥ (30 pts)?
Not Eligible for Incentive Payment

15. MAV CLUSTER 16 - PATHOLOGY
#99 Breast Cancer Resection Pathology Reporting: pT Category (Primary Tumor) and pN Category (Regional Lymph Nodes) with Histologic Grade
#100 Colorectal Cancer Resection Pathology Reporting: pT Category (Primary Tumor) and pN Category (Regional Lymph Nodes) with Histologic Grade

16. PQRI Process NCH Visit Documented in the Medical Record Encounter Form
Critical
Step
Visit Documented in the Medical Record
Encounter Form
Coding & Billing
N-365
NCH
Analysis Contractor
National Claims History File
Carrier/MAC
Eligible professionals document fulfillment of measure requirements in the medical record.
Quality-data codes may be entered onto an encounter form.
Codes associated with measure(s) are captured for the claims submission process.
Claim is submitted to Medicare claims processing contractor for processing by the National Claims History file.
Confidential Report
Incentive Payment

17. E-Prescribing Incentive Program
MIPPA authorized a new incentive program, separate from PQRI, for EPs who are successful e-prescribers
For 2009, successful e-prescribers are eligible for a incentive payment equal to 2% of estimated allowed charges submitted by 2/28/2010
2009 E-Prescribing Incentive Reporting Period: January 1, 2009 – December 31, 2009
MIPPA also requires that names of eligible professionals who are successful e-prescribers be posted on the CMS web site

18. 2009 Successful E-Prescribers
“Successful E-Prescriber” is defined as an EP who reports the e-prescribing measure established for PQRI (i.e., Measure #125) for at least 50% of applicable Medicare Part B FFS patients using a qualified system
E-prescribing measure is reportable only through claims
Limitation to applicability of incentive payment
Denominator codes for the e-prescribing measure must comprise at least 10% of an EP’s total allowed charges for all covered services furnished by the EP during the reporting period

19. 2009 E-Prescribing Process
Critical
Step
PBM
Encounter Form
Coding & Billing
Visit Documented in Medical Record & Rx Generated
Rx Trans-mitted to Pharmacy
N-365
NCH
National Claims History File
Carrier/MAC
Analysis Contractor
Eligible professionals document fulfillment of measure requirements in the medical record.
Quality-data codes may be entered onto an encounter form.
Codes associated with measure(s) are captured for the claims submission process.
Claim is submitted to Medicare claims processing contractor for processing by the National Claims History file.
Confidential Report
Incentive Payment

20. Reporting Scenarios E-Prescribing
A 70 year old male patient presents to the clinician’s office for medical care.
Scenario 1:
The clinician discusses current medications and prescribes new medication, updates active medication list in eRx system, transmits prescription electronically to pharmacy
Reports G8443
Scenario 2:
The clinician documents there is no change in meds, no prescription generated.
Reports G8445
Scenario 3:
Pt has mail order pharmacy that cannot accept eRx & asks for hard copy. Physician updates meds in eRx system, eRx system provides hard copy of prescription to patient.
Reports G8446
All of these scenarios represent successful 2009 reporting

21. What is Not E-Prescribing
Calling in a prescription for NH patient
Patient seen in ED and is sent home with a prescription
Faxing a prescription to a pharmacy
Sending a prescription via PDA (exception: depends on software used – must meet e-prescribing system qualifications)
Knowingly sending a computer-generated fax initiated at the doctor’s office to a pharmacy (exception: if sent via qualified e prescribing system and pharmacy system generates message as a fax, it is e-prescribing)
Office visits provided as part of a global surgical package
Medicare Advantage patients (exception: some private fee-for-service plans - can e-prescribe, but this does not count toward incentive payment calculation)

22. Reporting Measures with Claims
This example illustrates the difference between the base claim dx and the line item dx as well as the NPI placement (different from the billing NPI in box 33a).
The patient was seen for an office visit (99213). The provider is reporting several measures related to diabetes, coronary artery disease and fall risk:
Measure #2 (LDL-C) with QDC 3048F + diabetes line item dx ;
measure # 3 (BP in Diabetic) with QDCs 3074F F + diabetes line item dx ;
measure #6 (CAD) with QDC 4011F + CAD line item dx ; and
measure #4 (Falls) with QDC 1101F. There is no specific diagnosis required for measure #4 denominator inclusion.
Also very important is the NPI placement: Box 24J, which must be included on the QDC line item in order for the NPI to receive credit for the measure.
The Tax-ID associated with the NPI(s) on this claim is shown in Box #25.

23. PQRI Tools: Where to Begin
Gather information and educational materials from the PQRI web page: on the CMS website (e.g., Measures/Codes, Educational Resources, Tool Kit web pages).
Gather information from other sources, such as your professional association, specialty society or the American Medical Association.
Overview
CMS Sponsored Calls
Statute/Regulations/Program Instructions
Eligible Professionals
Measures/Codes
Reporting
Analysis and Payment
Educational Resources
FAQ updated daily
Specialty societies and associations often give coding advice; as does the carriers

24. Understanding the Measures: PQRI Quality-Data Codes
Quality-Data Codes translate clinical actions so they can be captured in the administrative claims process
The measure requirement was met – OR –
The measure requirement was not met due to documented allowable performance exclusions (i.e., using CPT II performance exclusion modifiers)
– OR –
The measure requirement was not met and the reason is not documented or is not consistent with an accepted performance exclusion (i.e., using the 8P reporting modifier)

25. Understanding the Measure Construct
NUMERATOR
CPT II Code or Temporary G Code
(describes clinical action required for performance) ÷
DENOMINATOR
ICD-9-CM & CPT Cat I Codes
(Describes eligible cases for a measure: the eligible patient population as defined by denominator specification)

26. Understanding the Measures: The Performance Modifiers
Unique modifiers used with CPT II Codes only
Performance Measure Exclusion Modifiers indicate that an action specified in the measure was not provided due to medical, patient or systems reason(s) documented in the medical record:
1P- Performance Measure Exclusion Modifier due to Medical Reasons
2P- Performance Measure Exclusion Modifier used due to Patient Reason
3P- Performance Measure Exclusion Modifier used due to System Reason
One or more exclusions may be applicable for a given measure. Certain measures have no applicable exclusion modifiers. Refer to the measure specifications to determine the appropriate exclusion modifiers.
If a measure has no applicable clinical performance exclusion modifiers, then if the action was not performed for any reason the professional should report the 8P reporting modifier in order to support successful reporting.

27. Understanding the Measures: The Reporting Modifier
Performance Measure Reporting Modifier
facilitates reporting a case when the patient is eligible but the action described in a measure is not performed and the reason is not specified or documented
8P Modifier: action not performed, reason not otherwise specified

28. Understanding the Measures: Performance Time Frame
Some measures have a Performance Timeframe related to the clinical action that may be distinct from the reporting frequency.
Perform within 12 months or annually
Most Recent result
Clinical test result needs to be obtained, reviewed, reported one time.
It need not have been performed during the reporting period.

29. Understanding the Measures: Reporting Frequency
Each measure has a Reporting Frequency requirement for each eligible patient seen during the reporting period
Report one-time only
Report once for each procedure performed
Report for each acute episode

30. 2007 PQRI Experience Report
12.15% (1,711,975) of QDC submission attempts were associated with a missing NPI
18.89% (2,662,023) of QDC submission attempts occurred with an incorrect HCPCS code*.
13.93% (1,963,196) of QDC submission attempts occurred with an incorrect DX code*.
7.24% (1,019,422) of QDC submission attempts occurred with both an incorrect HCPCS code and incorrect DX code*.
4.97% (700,201) of QDC submission attempts occurred on claims where all line items were only QDCs
*Denominator mismatch

31. Benefits of PQRI Participation
You will receive confidential feedback reports to support quality improvement
You may earn a bonus incentive payment
You will be making an investment in the future of your practice
Prepare for higher bonus incentives over time
Prepare for pay for performance
Prepare for public reporting of performance results
Every reporting provider receives report how performing compared to peers.
Learn now before pay for performance with no risk
Be ready in near future when full P4P
Predict: Congress will add P4P if it maintains fee schedule.

32. PQRI Website: www.cms.hhs.gov

34. Additional Resources ______________________________
Centers for Medicare and Medicaid Services:
Physician Quality Reporting Initiative:
Hospital Quality Reporting:
Open Door Forums:
National Provider Identifier:
Demonstrations:

35. Thank You
For questions about PQRI you may
contact your Regional Office, Carrier, or
Submit a comment through the website