PQRI: Money on the Table

Twitter icon
Facebook icon
LinkedIn icon
e-mail icon
Google icon

Medicare made more than $36 million in payments to more than 56,000 physicians who participated in the Physician Quality Reporting Initiative in 2007. That’s the good news. The bad news is that only about half—52%—of the physicians who participated got paid, Bibb Allen, MD, chair, ACR Commission on Economics, told attendees at a special focus session on Implementations of Pay for Performance: Implications for Radiology on December 1, 2008, at the annual meeting of the RSNA in Chicago.

“The bottom line here is that there is a lot of money being left on the table that Medicare is authorized to spend, if physicians are willing to participate,” Allen says, adding that the ACR estimates that just 10% of radiology practices participated in the program, a rate believed to be similar to the overall physician-participation rate. The ACR also believes that the radiologists’ success rate was comparable to the overall 52% reporting-success rate.

Allen explains that the program was legislated through the DRA of 2005, better known for its draconian cuts to reimbursement for the outpatient imaging technical component.

“The program went live in July 2007, with a total of 74 measures available for reporting,” Allen notes. “Radiology had two measures, radiation oncology had one, and there were four perioperative-care measures that could apply to interventional radiology.” Radiology’s two measures related to stroke and rehabilitation and involved carotid-imaging reports and CT or MRI reports.

“The bonus was 1.5% of total Medicare revenue, although there were some caps in 2007,” Allen reports. “Physicians had to report 80% of eligible cases to qualify for the bonus, and had to report on three or more measures if they were available (both measures, in the case of radiology). You don’t enroll; you just had to submit claims properly.”

Reporting Issues

Complying with the claim system is not trivial, Allen notes, and this is the likely cause of the 52% success rate (physicians are required to submit claims at the individual-provider level using the National Provider Identifier, but CMS did agree to make aggregate payments to groups under a single tax-identification number). Compounding the reporting problems was a delay in feedback on 2007 results, which CMS did not provide until well into 2008. This virtually ensured that those who had problems in 2007 would repeat them in 2008.

Radiology had expected an additional eight new measures for 2008, but because they were not written into the proposed 2007 Medicare Physician Fee Schedule, CMS could not include them, Allen reports. Changes affecting radiology amounted to some alterations in applicable ICD-9 codes. CMS also removed the cap on payments, so that physician groups that successfully reported three or more measures would receive the full 1.5% of total Medicare revenue (not just the revenue associated with the measures). The largest award to a practice in 2007, when the cap was in place, was $205,700, but the average group payment was $4,700.

“The biggest change is that there were no caps in 2008, so we hope the money will be a little bit more than $36 million,” Allen says. “They saved $1.8 billion from the DRA, so they have money to spread back to the physicians, for sure.”

For 2009, radiology got two new measures, and all physicians will receive a 2% of Medicare payments instead of 1.5%—if they report successfully—meaning that participating radiologists will have to report on three of the four total measures. The new radiology measures aim to curtail the inappropriate use of ACR BI-RADS® category 3 in mammography screening and to limit radiation-exposure time for procedures that use fluoroscopy.

Allen offered guidance on reporting the four radiology measures, but was not optimistic about the ability to report fluoroscopy times successfully in 80% of cases. Successfully reporting each measure entails a two- or three-step process, but strong coding support is also important. “Its all about billing and coding,” Allen says, “but what you, as radiologists, have to do is make sure your radiology report is structured so that your coders can find out what you’re doing.”

Stroke and Stroke Rehab—Carotid Imaging (Measure 11)

Step 1.—Decide whether the patient is eligible; in this case, he or she must be a Medicare patient over 18 who has a carotid imaging study and a diagnosis of ischemic stroke or transient ischemic attack (TIA).

Step 2.—Does the patient meet the measure? Does the