PQRI: Money on the Table

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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 report include direct or indirect reference to measurements of distal internal carotid-artery diameter as the denominator for stenosis measurement? If yes, then you report category-II CPT® code 3100F. If no, and medical reason for reporting is provided, report 3100F-1P. If no, and no reason is provided, you have to report CPT category-II 3100F-8P. Stroke and Stroke Rehab—CT/MRI Brain (Measure 10) Step 1.—Is the patient eligible? He or she must be a Medicare patient over 18 who has had a CT or MRI exam of the brain plus a diagnosis of (or symptoms consistent with) ischemic stroke, TIA, or intracranial hemorrhage. If all of the above are true, proceed to steps 2 and 3. Step 2.—Does the patient meet the measure? Was the CT or MRI exam performed with 24 hours of arrival? If no, stop and report only 3112F. If yes, report 3111F and proceed to step 3. Step 3.—Was it documented that there was the presence or absence of hemorrhage and mass and acute infarction? If yes, report category-II CPT code 3110F (in addition to 3111F). If no, also report category-II CPT code 3110F-8P (in addition to 3111F). “Here are the associated CPT codes (0042T, 70450, 70460, 70470, 70551, 70552, and 70553) that your coders will report,” Allen says, referring to the CT/MRI Brain measure. “If you would like to dictate those, you could, but ideally, you will have a system whereby your coders would pick that up through that process.” Inappropriate Use of Probably Benign Assessment (Measure 146) Step 1.—Is the patient eligible? She must be a Medicare patient aged 18 years or older for whom a screening mammogram is performed. Step 2.—Does the patient meet the measure? For documented mammogram-assessment categories, report these codes:
  • incomplete (BI-RADS 0), report CPT category-II 3340F;
  • negative (BI-RADS 1), report CPT category-II 3341F;
  • benign (BI-RADS 2), report CPT category-II 3342F;
  • probably benign (BI-RADS 3), report CPT category-II 3343F;
  • suspicious (BI-RADS 4), report CPT category-II 3344F;
  • highly suggestive (BI-RADS 5), report CPT category-II 3345F; and
  • cancer, under treatment (BI-RADS 6), report 3350F.
This measure was brought about because, as Allen explains, “A patient undergoing a probably benign screening mammogram probably shouldn’t go straight to a six-month follow-up examination. All you have to report is that there is a screening mammogram and that there is a BI-RADS number assigned. If there’s screening, and it’s a BI-RADS 3, you are going to get dinged, and if more than 20% look like that, you will not make the measure.” Exposure Time Reported for Procedures Using Fluoroscopy (Measure 145) Step 1.—Is the patient eligible? He or she must be a Medicare patient aged 18 years or older undergoing a procedure that uses fluoroscopy. Step 2.—Does the patient meet the measure? Radiation exposure or exposure time must be reported in the final report and coded as CPT category-II 6045F. Radiation exposure or exposure time not in a final report using fluoroscopy must be coded as CPT category-II 6045F-8P. Because there are a total of 229 CPT codes for which fluoroscopy can be used (and thus too many failure points), Allen is not optimistic about radiology practices achieving the 80% compliance rate needed to get paid. “I’m thankful that there are three measures that we can report without doing this one, because I think this is going to be a hard one,” Allen concludes.