The quality movement, a driving force in how hospitals manage and measure patient care, will soon reach clinicians’ offices nationwide. On July 1, the Centers for Medicare & Medicaid Services (CMS) will launch a new Physician Quality Reporting Initiative (PQRI). A variety of healthcare providers who see Medicare patients can participate in the voluntary program—and earn a bonus on their Medicare reimbursement.
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Explore This IssueJune 2007
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Providers from 19 different categories can participate, including doctors, nurses, social workers, psychologists, dieticians, and physical and occupational therapists. CMS has established specifications for 74 quality measures eligible for reporting under the six-month program. Six of the measures are relevant to treatment of adult rheumatology patients—five pertain to osteoporosis and one to falls. (See “PQRI Rheumatology Quality Measures,” below.)
Physicians interested in participating simply need to report these quality measures to Medicare on their reimbursement claims (paper form CMS 1500 or electronically) using the appropriate Current Procedural Terminology (CPT) Category II codes or G-codes. Reimbursement for the codes should be listed as $0.00, as this field cannot be left blank. The codes will appear to be denied, but the quality-data codes reported will be accepted into the system, analyzed, and considered in bonus payment eligibility calculations. The 2007 reporting period is July 1 through December 31. The incentive for reporting is a 1.5% bonus on total allowed charges submitted for professional services under the Medicare Fee Schedule. “Our goal is to transform Medicare from being a passive payer to an active purchaser,” says Thomas Valuck, MD, director of the special program office for value-based purchasing at CMS.
“It is important to realize that this is just the first step in a CMS program that is moving toward quality-based reimbursement,” says Larry Anderson, MD, director of quality improvement for MaineHealth, Maine Medical Center Physician Hospital Organization in Portland and a member of the ACR’s Quality Measures Committee. “You get paid for reporting [alone], but that will migrate to paying for results and performance. While the bonus of 1.5% may not be enough to entice people to [participate], it’s an opportunity for practices to gain experience reporting these kinds of performance measures because it’s going to be commonplace in years to come.”
Participating now will help providers improve their processes and to compare themselves with providers nationwide through confidential feedback reports. In the future, “the amount of money at stake might increase,” says Dr. Valuck, and it might be based on outcomes, with congressional approval. Additionally, the results might become public. “This is an opportunity to [prepare] for a more intensive pay-for-performance program,” he says.
“While the bonus of 1.5% may not be enough to entice people to [participate], it’s an opportunity for practices to gain experience reporting these kinds of performance measures, because it’s going to be commonplace in years to come.”
Bonus Nuts and Bolts
In this first step, providers will not be required to report outcomes, but rather only whether they performed an action reflected in the measure. Providers will be asked to report if a patient has had a certain procedure based on the eligible quality measures. For example, if a female patient age 65 or older had a DXA ordered or performed at least once since age 50 or medication prescribed within 12 months. You have to document this in your record in case of audit.