How To Be Successful With PQRI

I had a meeting today at our CPT medical coding company to help understand how Happy's Hospitalist group could increase success with our CMS physician pay for performance PQRI.  As you may or may not know PQRI is the name given to the, as of current, voluntary quality reporting reporting program for physicians.  If they successfully complete the goals outlines by the the Medicare National Bank (MNB), physicians can earn up to a 1.5% additional payment for all Medicare claims.  In 2009, that number goes to 2%.

So here's how the program works.  The MNB has a list of over 100 indicators that physicians can chose to report on.  Things like checking HgBA1C for diabetics,  monitoring blood pressure,  assessing fall risk,  evaluating for beta blocker use in heart failure.  There's a ton of them.  But we physicians don't need to report all of them.  How many?

Just three.  But here's the catch.  You must report at least 80% of the time on qualified patients on all three of those indicators or you don't get any money.  None.  If you meet the qualifications for two of them with 100% and the third indicator is 79%, you get nothing.

For the reporting period of July-December 2007  Dr Happy was the only physician in his group of almost 20 that successfully achieved the 80% mark on three indicators.  And with that, Dr Happy took home a walloping $1,100 bonus, before taxes.  For all the time and energy spent by our billing company.  For all the time and energy spent by me and all my partners.  $1,100.  That's what we had to show for it.

So what does it take to qualify?  Well, it can be very complicated.  I had a meeting today  with our billing company to try and figure out how we can increase the success rate going into 2009.  Eventually, what started as a bonus, will become punitive,  I'm sure of that.  I have no doubt in my mind.   That's the way all other quality indicators have progressed on the hospital side of the equation.

So let me break it down for you.  Let me pick just one quality indicator that we have been reporting on.  Our group picked four out of the hundred or more quality indicators.  We picked one extra to give us some breathing room.  Only 3 of those 4 must qualify.  So let's look at coronary artery disease.  The quality indicator was:  Is a patient with coronary artery disease being prescribed antiplatelet?  For simplicity,  antiplatelet will mean aspirin in this discussion.

How does one report?  Well.  It gets very complicated.  So here goes.  I'll try and explain.  There are several aspects to the reporting that must all come together by some sort of stroke of luck from the Heavens for success in the program to be achieved.

1. Which CPT code is the quality indicator good for?  This is one of the most important aspects.  Just because I saw the patient does not mean I can report to the PQRI system on that patient.  Only certain CPT codes qualify.  Remember CPT stands for Current Procedural Terminology.  Whenever you have any possible billable encounter, your doc must submit the CPT code via the third party insurance rules per their contract.   A mid level hospital follow up--> CPT code 99232.  A critical care evaluation in the ICU-->99291.  Reading an xray?  Performing a heart cath?  They all have their own CPT codes.    So you have to know which CPT codes your quality indicator is good for.  For aspirin use in coronary artery disease,  the MNB accepts it for hospital discharge codes, consult codes, outpatient consult codes, among others.  You can report to PQRI for all your CPT encounters with this patient, but the MNB will only accept it in the denominator of your numbers if the encounter is one of their approved CPT codes. The rest is just wasted energy.  Reporting to PQRI on CPT codes that aren't approved won't get you anything but an increased overhead in time and energy.   So you have to get past this step.  Let's say, for arguments sake, that I discharge a patient from the hospital, using CPT code 99238.  The MNB says this CPT code CAN be used to report aspirin use for CAD to PQRI.  The PQRI system does not care how many qualifying patients you report.  If you only submit one patient all year for aspirin use in CAD and if you document it appropriately, then you have 1/1 on your report card.  You are 100%.  You meet the threshold of 80% for that one indicator and you are successful.  Remember you need to report three quality indicators.  It seems easy,  but it's not really.  It gets a lot more complicated.  
2. Are you  linking the ICD code with the qualifying CPT code?  The ICD code or International Classification of Disease is the disease.  In this case, coronary artery disease (414.0).  When ever a doctor submits a CPT code to the insurance company to get paid, that CPT must be linked to an ICD code.  This is to protect the insurance company from scrupulous doctors submitting office visits for such things as "talking about the football game".  For insurance to pay a doctor for their CPT visit, there must be a linking to a disease.  So all disease have their own ICD code.   In this case the ICD code for coronary artery diseas is 414.0.  Now here's the kicker.  If you submit a claim to the MNB to be paid for a 99238 (a hospital discharge code AND an allowable CPT code for PQRI for the  the quality indicator for aspirin use in CAD) and you link the CPT code to ICD code 414.0, but you FAIL to report to PQRI, you have just lost a patient on your numerator.  For example.  Lets say you have 2 patient all year with CAD who you saw and who's CPT code would qualify them for PQRI reporting.  Lets say patient one you link ICD code 414.0 (CAD) to your claim to Medicare for CPT code 99238 and you report to PQRI.  You have successfully complete 1/1 claims.  You are 100% successful on your reporting for that one quality indicator.  Now,  lets say patient number 2 has CAD and you successfully link your ICD  for CAD, 414.0, to your CPT code for discharge, 99238, but you FAIL to fill out the appropriate reporting (to be discussed shortly) to PQRI.  Your have now increased your denominator to 2, but you have only reported on 1/2 patients.  So your successful reporting is only 50%.  Remember PQRI requires you to report on 80% of your qualified patients.  In this case, because you failed to report to PQRI on just 1 of 2 patients, even though you submitted to the MNB to get paid for your office visits,  your 50% does not qualify, and this quality indicator thus fails.  Remember, you must pass 80% on at least three different quality indicators to get your 1.5% bonus.  So depending on how many different quality indicators you chose to report, you can still make it up on other quality indicators.  Another common area to fail in the reporting game is failure to link the ICD, 414.0, to the CPT code 99238 when submitting to PQRI.  Many patients we see have 10, 15 or 20 medical problems/ICD codes.  When you submit a claim to the MNB, they will only accept 4 ICD codes.  If a patient has pneumonia, hypertension, COPD and diabetes, AND CAD, and you submit your CPT code to the MNB on discharge code 99238 using the ICD codes for pneumonia, hypertension, COPD and diabetes, BUT you fail to include the ICD code for CAD (414.0), then the MNB will not include this patient in your denominator for PQRI reporting.  For reporting purposes, it is as if this patient does not exist.  Even though they have CAD, since you did not link the ICD for CAD (414.0)  to your qualifying CPT code 99238 for quality indicator aspirin use in CAD, this patient will not apply to your denominator for reporting purposes.  In the course of a year, this can hurt you because the fewer patients that you qualify, the fewer screw ups you can tolerate and still hit 80%.  You see,  reporting correctly on 80/100 patients is alot easier than reporting correctly on 1/2.  Your margin for error is far greater the more  patients you qualify to report on.  So failing to link the ICD code to the appropriate qualifying CPT code can only hurt you in the long run.  
3. What exactly are we reporting?  Good question.  Now that we've gotten past to first two steps of making sure you know what the qualifying CPT codes are AND then making sure you link the qualifying ICD code to the CPT code,  what exactly to we do next?  Well,  in the case of the aspirin use in CAD, it's not simply reporting yes or no.  Of course not.  It couldn't be that simple.  For each possible quality reporting indicator, we docs have the choice of 3, 4, 5 or more choices to report to PQRI. And each choice has its own code.  Of course it does.   In the case of aspirin use?  We can report 
• Aspirin prescribed code 4011-F
• Aspirin not prescribed for medical reasons 4011F-1P
• Aspirin not prescribed for patient reason (social reasons or declined) 4011F-2P
• Aspirin not prescribed for a system reason (insurance/resources unavailable)   4011F-3P
• Aspirin not prescribed, reason not specified 4011F-8P

Got It?  So here's the summary.  The MNB puts out a list of a hundred + quality indicators that they believe represents a marker of quality health care.  For physicians who wish to participate, they must report data on at least 80% of the patients that qualify (the denominator) for at least THREE indicators.  Physicians can report as many indicators as they want, but the minimum is three, and you don't get any extra money for reporting more.

Once you've decided which indicators you want to report,  it doesn't matter how many patients you have on each indicator.  Your denominator could possibly  be only one patient.  If you successfully report only one of one patient for all three indicators, you have achieved 100% success in the PQRI program, and the MNB will cut you a check in 2008 for 1.5% of ALL your Medicare billings.

But it's not that simple.  If you have a patient that would qualify in the denominator (appropriate CPT code for the quality indicator) AND has the appropriate ICD code to report (CAD/414.0) but you  if you choose not report to PQRI, your denominator increases and your numerator stays the same.  This would put you at risk for not meeting the 80% requirement.

This is what happened to the vast majority of folks in Happy's Hospitalist group.  We all met the required number of patients for each quality indicator.  That would be at least one patient, because there is no minimum threshold to meet.  However, most of Happy's partners linked the ICD code to the appropriate CPT code, but failed to submit to PQRI ( or not, read below).  They failed to circle one of the five 4011-F codes (or not).  So most of the quality indicators came in under 80%.  Most denominators were in the 5-15 patient range.  So you can see, failure to submit just 1,2 or 3 PQRI claims can destroy a whole years worth of effort.  And keep you below the 80% threshold.

So the question becomes, from a systems standpoint, why are the appropriate PQRI claims not being filed.

• Are the docs failing to circle the appropriate 4011F code?  Are they simply forgetting about it?  Quite possibly.  
• Is our billing company failing to submit to PQRI?  Every step in the process involves human interaction.  And that leaves room for failure
  
• Is Medicare screwing up on there end?  Are claims being submitted but lost?  I wouldn't doubt it for a second.  I have heard that Medicare had to hire a whole slew of subcontractors to deal with the flow of paper coming through the PQRI program.  I'm sure they are less than perfect.  And when you are dealing with small denominators, it doesn't take much to screw you.
• Is Blue Cross screwing us?  I learned today that a plausible scenario involves private insurance as the primary and Medicare as the secondary.  When we submit a claim, that would qualify under the  PQRI denominator, to the primary private insurance, it is up to to the Blue Cross of the world to forward our PQRI information on to Medicare.  I can almost bet you that that will never happen.  There is simply no incentive for them to pass it on.  When Medicare, as a secondary, gets the bill, they will have patients that qualify in the denominator for PQRI reporting, that will never get reported.  That almost certainly will decrease the 80% reporting rate when you are dealing with denominators less than 20.

And there is no way to know where the errors are occurring.  Medicare does not tell you which patients qualified, which didn't.  Which patients you failed to submit but should have.  It's a giant black hole of faith.  Faith that paper pushers in the entire data trail have done their job correctly, so you doc, get your $600 bonus, the average paid out last year.

It's no wonder why less than 1/3 of doctors  have chosen not to play.   So much time  So little money.  And no way to verify that everyone else, is keeping up their end of the bargain.  It's no wonder this program is a laughing stock of administrative cost and burden.  Unfortunately, since this program will eventually become punitive, like every quality program before us,  learning how to game it now, will guarantee years of successful average PQRI bonus checks in the future.  It will also guarantee a whole generation of jobs in government, jobs that do nothing but push paper from one cubicle to another.  But then again, that's what government does best.

And imagine,  when ICD-10 comes along, this whole process will be 10 times harder.  That's why if you are a doctor and a patient that can take the risk of leaving the insurance pool for your less than catastrophic care, you need to do it now.  Into a cash based system that values you as a patient, not as a CPT and an ICD code.