It looks like I have learned to game the system. Which is what PQRI has felt like since I started keeping track July of 2007. A giant game. PQRQSucker is a voluntary system (for now) that pays physicians extra money for quality. Our group is a bit old school. We do it by hand. Us docs decide what level to bill on our own billing cards we carry around.
On the flip side is our PQRI feature here: click image to enlarge
What you'll notice is that our group chose 4 quality indicators to report on. The rules by the Medicare National Bank state you only need to report on 3 indicators 80% of the time. If you do that, they will pay you a (I believe) a 1% bonus on your Medicare charges for the year (in this case six months from July 1-Dec 31 2008). You'll notice the silliness in the reporting. It doesn't matter what I checked, only that I checked something.
Notice the not documented; reason not specified. Seriously. This is CMS quality reporting.
Actually, I believe it's just a data hunting expedition. Eventually, we will have to report this and reporting not documented; reason not specified will likely result in a deduction of payment. It's all a prelude to a cost cutting expedition, I suspect. What you'll also notice is the lack of rhyme or reason to when you can report which quality indicators.
The antiplatelet therapy prescribed at discharge for patients diagnosed with stroke or TIA is only good on discharge codes 99238 and 99239 as well as inpatient consult codes 99251, 99252, 99253, 99254, 99255. Since we admit just about every stroke patient, it makes no sense why I can't document this quality indicator on my admission code, but the neurologist can (because they are the consultant). If I admit on a night shift and go off service, I can't use that patient as a quality reporting patient. The same goes for the oral antiplatelet therapy for patients with coronary artery disease. We hospitalists can only report it with in patient consult codes, discharge codes or outpatient rehab or outpatient consult codes. Same situation. If I admit, but don't discharge because I go off service, I can't use this patient as a quality indicator, but the specialist can because they are collecting the consult code.
So this little game I play with every single patient I see is
- Check to see if the nurses have documented code status or advanced directive plans in the chart (part of admitting nurse documentation). I fill out my card for every person over 65 based on that paper work. If I admit a patient before that work has been done, I indicate it is not documented, reason not specified. And I leave it at that. It is an accurate statement at the time of my evaluation, even if it's not accurate 24 hours later.
- I check to see if the patient has a history of coronary artery disease OR stroke. If the answer is yes, I make 100% sure that I link that diagnosis with the discharge code on discharge day (if I'm the discharge doc), or the consult code in the rare instance that I consult on these patients. If the patient merely has a history of stroke or coronary artery disease, I make sure that ICD diagnosis is linked, even if they are admitted for a stubbed toe. That way I guarantee that I get patients for my quality reporting data base. It's a game. Go back and look at the card again to see how complicated the process is. Only certain E&M codes are allowed, and you must link the allowable ICD codes with that E&M code when submitted. If a patient has a history of coronary artery disease but I don't link CAD with my discharge E&M code 99239, that patient won't count for PQRI reporting and. If the patient has CAD and I do use that as an ICD code but don't submit a PQRI for it, I won't achieve my 80% requirement.
So how did our group turn out this year? About 17 of us docs. How many of us qualified for our 1% bonus? Here's the news:
We Received 2007 PQRI payments of $1,100 from WPS Medicare and $63.00 from Railroad Medicare. According to the report that we pulled from the secured CMS website (IACS), the total amount of $1163.00 is an incentive payment for Dr. Happy. He is the only physician that 'reported satisfactorily'. All other physicians did not earn the incentive as 'insufficient # measures reported at 80%'. In order to receive the incentive you had to report > 80% of eligible patients on at least 3 measures. Dr Happy reported > 80% on 4 measures while the other physicians reported 80% on 1 or 2 measures only.
I knew without a doubt I would get my bonus. The question was how much. Because I learned how to play the game of the system. It's a game, I can assure you. I can count on one hand in that six months the number of times that PQRI made me order a baby aspirin for a patient with CAD, that wasn't on it previously. And they were usually of very advanced age, and in very poor shape to begin with. They are patients that jumped ship from the prevention boat years ago, living out their final years in a constant boarding and unboarding at our hospitel. I suppose CMS sees that as a ROI of at least $1,000 if just one of those CAD patients fail to return to the hospital for an MI. Unfortunately, my patient population with CAD or stroke will return to the hospital 100% guaranteed for any one of their other 10 comorbid medical conditions. I don't see Medicare folks in the hospital with isolated CAD. I see them with 20 medical problems of which CAD is but just one of their issues, and almost always the least of their worries.
Was it worth the time and effort for our billing company to submit 1000's upon 1000's of PQRI claims only to have me, Dr Happy get a small post tax bonus of about $700? I think most groups could answer that with a resounding no. I have no idea how much my billing company charged us to submit all these claims or if they did it for free. I can assure you the whole process in time and resource utilization ran well over $1000. You can see how such a process can be very labor intensive for staff or docs to document, and get so little in return. A thousand bucks is a lot of money, but not when you consider, the time I spent, and the time of the billing company, and the time of Medicare auditors and their paper trail. One needs not wonder why so few physicians participated in the project (15%), of which only 1/2 got any money at all. And the average paycheck was $600. I suppose I'm one of the suckers with a $1000 check coming my way. To that I say:
Who's your friggen Daddy.
What is the "penalty" now or in the future for ignoring this whole game, as some of your partners have done.
ReplyDeleteMoney is not an incentive. It rarely is when one makes above a certain level of income (some famous sociologist did a study which has his name on it that shows this - I dunno what it is though - tuned it out I think).
Personal gratification is not an incentive for most in healthcare, unless it comes directly from a patient, family or colleague - at least in my experience.
Threats of being displaced (fired) are incentives if they prove to be true. Often they are empty threats by puffed up hospital administrators.
So - will you do it again? Is that $700 check enough of an incentive to be this diligent (one might say obsessive) with your coding? I'm sure all of you are competent - even good physicians. But, the coding game is one that a high school graduate who is trained in coding & key words or phrases could do. That is usually the bulk of the medical records staff with one or two who have actually obtained a degree in hospital administration or related field.
Just thoughts....
anon, the penalty will perhaps be a deduction in pay for not doing it, as opposed to a "bonus" for doing it. Will I continue to do it? I don't know. I'm doing it for 2008, but that may change. I haven't decided yet.
ReplyDeletefrom what my attendings told me last year, i think most physicians expected a much larger check than was passed out/given out/earned.
ReplyDeletei'm interested to know if the purported penalty would be equal to the pay out. i.e. physicians who keep up with this game get, on average, $600... so physicians who don't keep up with this game get, on average, $600 taken away from them.
my next thought would be does this initiative just assume that most physicians won't want to do all of this extra paperwork, and therefore everyone will get dinged, thereby saving the system money by virtue of not actually doing anything. in other words, from what you wrote, the cost of you filling out that paperwork may not be worth the benefit.