1 / 27

The ABC’s of PQRI in the SNF/NF setting

The ABC’s of PQRI in the SNF/NF setting. The ABC’s of PQRI. Presented @ Carolinas Medical Directors Assn. conference 10/9/2009 Rod Baird – presenter President of Geriatric Practice Management, Inc. Asheville, NC. Rbaird@99309.net

berg
Download Presentation

The ABC’s of PQRI in the SNF/NF setting

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. The ABC’s of PQRIin the SNF/NF setting

  2. The ABC’s of PQRI • Presented @ Carolinas Medical Directors Assn. conference 10/9/2009 • Rod Baird – presenter • President of Geriatric Practice Management, Inc. Asheville, NC. Rbaird@99309.net • Mr. Baird reports no conflict of interest associated with this presentation

  3. Origin of PQRI • The 2006 Tax Relief and Health Care Act required the establishment of a physician quality reporting system, including an incentive payment for eligible professionals who satisfactorily report data on quality measures for covered services furnished to Medicare beneficiaries. CMS named this program the Physician Quality Reporting Initiative (PQRI).

  4. PQRI • CMS – Medicare incentive program • Began in 2007 w/ 1.5% payment for successful participation • Incentive increased to 2% in 2009 • Proposed to continue in 2010 • 2010 data will serve as basis for public reporting of MD ‘quality’

  5. What is a PQRI Measure • Intent – to promote individual quality improvement • Measure types (process, outcome, etc.) • Subject population (age, diagnosis, etc.) • Exclusions from subject population • A specification (what is measured) • Frequency (annually, each encounter, etc,) • Location (specified by CPT or HCPCS)

  6. Measure Example Measure #1: Hemoglobin A1c Poor Control in Type 1 or 2 Diabetes Mellitus • Reporting Description: Percentage of patients aged 18 through 75 years with diabetes and an applicable CPT Category II code reported a minimum of once during the reporting period • Performance Description: Percentage of patients aged 18 through 75 years with diabetes (type 1or type 2) who had most recent hemoglobin A1c greater than 9.0%

  7. PQRI in the Nursing Facility • No measures are specific to LTC setting • 24 measures apply to LTC CPT Codes • A measure’s definition of ‘quality’ may not match ‘best practices’ for the LTC population. • Neither AMDA or AGS have proposed PQRI measures, nor published any guidance on their use.

  8. PQRI Participation • Claims Based • Individual • Measure Group • Registry • Measure Group

  9. Claims Based -Individual • Submit individual measures on claims • 24 measures apply to 99304-99310 codes • You must use a minimum of 3 measures in 80% of the eligible encounters (e.g. annual or each visit). • Some measures apply to nearly every patient in a nursing home • #47 Advanced Care Plan (≥ 65 y/o, and 99304-99310) • Others are highly restrictive • #12 Primary Open Angle Glaucoma (POAG): Optic Nerve Evaluation • patients aged ≥18 y/o with POAG who have an optic nerve head evaluation during one or more office visits within 12 months

  10. LTC APPLICABLE PQRI MEASURESfor 20092010 not published

  11. MEASURE GROUPS • Diabetes Mellitus Measures Group • DM is only measures group applicable to CPT 99304-99318 • Chronic Kidney Disease (CKD) Measures Group • Preventive Care Measures Group • Rheumatoid Arthritis Measures Group • Perioperative Care Measures Group • Back Pain Measures Group

  12. Diabetes Mellitus Measures Group: #1. Hemoglobin A1c Poor Control in Diabetes Mellitus Percentage of patients aged 18 through 75 years with diabetes mellitus who had most recent hemoglobin A1c greater than 9.0% #2. Low Density Lipoprotein Cholesterol (LDL-C) Control in Diabetes Mellitus Percentage of patients aged 18 through 75 years with diabetes mellitus who had most recent LDL-C level in control (less than 100 mg/dL) #3. High Blood Pressure Control in Diabetes Mellitus Percentage of patients aged 18 through 75 years with diabetes mellitus who had most recent blood pressure in control (less than 140/80 mmHg) #117. Dilated Eye Exam in Diabetic Patient Percentage of patients aged 18 through 75 years with a diagnosis of diabetes mellitus who had a dilated eye exam #119. Urine Screening for Microalbumin or Medical Attention for Nephropathy in Diabetic Patients Percentage of patients aged 18 through 75 years with diabetes mellitus who received urine protein screening or medical attention for nephropathy during at least one office visit within 12 months #163. Foot Exam Percentage of patients aged 18 through 75 years with diabetes mellitus who had a foot examination

  13. Diabetes Mellitus Measures Group – required steps to successfully report: #1. Hemoglobin A1c Poor Control in Diabetes Mellitus completed lab test needed for complete reporting. A1c level <9.0% for ‘quality’ outcome. #2. Low Density Lipoprotein Cholesterol (LDL-C) Control in Diabetes Mellitus completed lab test needed for complete reporting. LDL-C level <100 for ‘quality’ outcome #3. High Blood Pressure Control in Diabetes Mellitus Can test & report @ 1st encounter but ‘quality’ requires b/p less than 140/80 mmHg #117. Dilated Eye Exam in Diabetic Patient usually requires consultation w/ report to complete this quality mesure. #119. Urine Screening for Microalbumin or Medical Attention for Nephropathy in Diabetic Patients usually requires lab test to report successfully. #163. Foot Exam requires either more complete exam (possibly w/o higher CPT), or referral and report

  14. Reporting Measure Groups • Claims Based • 80% Sample of Eligible Patients • 30 minimum Patients for year • 15 minimum Patients after 7/1/09 (only pays 1% incentive) or • 30 Consecutive Eligible Patients • Registry Based • 30 Consecutive Eligible Patients

  15. Considerations • In 2010 – your data will be basis for public performance reporting. • TIP - Avoid reporting noncompliant behavior (a new admitted diabetic – no eye exam, no foot exam, missing labs?). • Key Strategy Point – your sample population is based on billed ICD-9 codes. If you don’t list 250.xx on bill, they wouldn’t count for diabetic measures

  16. Conisderations – cont. • Cost benefit ratio for 80% sample – • Potential Revenue • Medicare Charges(300 vsts./mnth x $80/vst) = $24K/month • PQRI Bonus $24K*12mnth*2% = $5,760 • Same $ effect as doing additional 1.8 visits/week • @ 50% overhead = $2,880 MD income • Added Costs • Clinician Time for review, documentation, coding • Added form?? • Medical Records – additional transcription and/or coding • Billing – additional codes on bills – • ~33% error rate in 2007 submissions

  17. Considerations – cont. • 30 sequential patient sample • Only works for Diabetes Measures Group in LTC encounters • Ordering/reporting cycle for eye & foot exams; only established patients reflect ‘quality care’ • Incorporation of foot exam in 99307-9 visit would not enhance ‘nature of presenting problem’ • Does your patient population qualify? • 30 diabetics < 76 years age • < 10% of typical NF census meets these criteria

  18. Recommended Strategy • If you have 30+ sample of eligible diabetics – use measures group • Identify active, and newly admitted elegibles • Order any missing tests • Queue sample for sequential visits (can intersperse ineligibles w/o affecting PQRI • Use billing worksheet to select HCPCS codes • Coordinate w/ billing dept. or use registry • NCMedSoc has $0 deal w/ docsite registry for members

  19. Alternate Strategies • Don’t have 30 eligible Diabetics? • Don’t participate • Complexity of reporting multiple individual measures hard to justify (caveat – may be mandatory in 2011!) • Higher risk for failure – too many variables • Some measures not = best care in LTC setting • Lobby AGS & AMDA for ‘chronic care’ measures group. • Requires new individual measures w/ identical denominator for measure

  20. Claims Based Strategy • Pick 3 Measures that you can successfully report on 1st visit: • One measure must be reported 15 times or more (minimum # goes into effect 2010) • Pick 1x/year measures • Pick process measures (ones you control -like ordering antiplatelet therapy for CAD) that do no harm • Develop a process, and templates for notes

  21. Recommended Measures for Claims Based Submission • #6 -Coronary Artery Disease (CAD): Oral Antiplatelet Therapy Prescribed for Patients with CAD • #47 – Advanced Care Planning • #110 – Influenza Immunization

  22. Template Example • [] Quality Measures • 4011F – oral antiplatelet therapy ordered for CAD • 1124F – patient unable to participate in Adv. Care Planning; no family member or POA is available • G8482 - orders for seasonal flu shot is present in patient record

  23. PQRI Preliminary Steps • To access PQRI Data (not payments), providers have to register w/ CMS for an online account. This requires: • Register in PECOS – providers whose last CMS form 855 submission was 2006 or earlier may not be in PECOS and will have to reregister. • Register in IACS – this is portal for PQRI reports. Requires PECOS eligibility prior to registration. These processes will test your patience and leave you questioning the wisdom of a single payor system.

More Related