Implementing PQRI measures in Two Subspecialty Practices at UT Medicine

Maureen Sheehan, M.D., Vascular SurgeryKent L. Anderson, MD, PhD, Ophthalmology

Aim Statement

Implementing a method to capture documentation of appropriate PQRI measures in vascular and ophthalmology clinics to allow

for reimbursement (≥ 80% in ≥ 3 measures) within the next 4

months.

TEAM PQRI

Kent Anderson, MD, PhD

Jay Collins Administrator

Edward Kennerdell

UT Medicine

Andrew Krecek

IT Services

Amruta Parekh

Facilitator

Susan Hilgers

EPIC

Marti Pons

Finance

Maureen Sheehan, MD

NO PQRI

Staff

Physicians System

CAUSE and EFFECT DIAGRAM

IT support

Time

Value?

Time

Education

Institution

Burden

Interest

Coder Review

Data Entry

Burden

Building codes

Build/Transmit codes

Competing Priorities

Education

Education Expense

Enforcement

Politics

Consensus

Mixed input

Complex, unclear implementation instructions & directions

Software/Hardware

EMR system +/-upgrade

Pharmacies not in

Audit system

What is PQRI?

• Voluntary physician quality reporting incentive program

–Medicare Part B covered professional services (NPI)

–Became law; 12/2006; Reporting began 07/2007

–2007 – 2008: 1.5 % 2009 – 2010: 2%

–2011: 1.0% 2012 - 1014: 0.5%

–2015: -1.5%; 2016 - ?: -2.9%

–179 measures (2010); 13 measure groups

• Numerator: Clinical Action required

• Denominator: Eligible cases (Patient population)

How do we report PQRI?

• Report the entire calendar year (may also report 6 months starting in July)

• Report ≥ 3 measures or a single measures group on a specified group of patients

–HIV, ESRD, CAD, CHF, CABG, Rec, MEL, CA, LBP, CAT

• Report for ≥ 80 % of cases for which measure is reportable

• Claims or Registry or EHR

–PQRI CPT II codes, G codes, & P modifiers

–CMS qualified registry; one submission annually

Why must we do PQRI?

• Our colleagues do it

–AAO: 2008 (42%); 2009 (52%); 2010 (57%)

–Success rate in 2008 was 48%

–32% use an EMR; 52% E-prescribe

• Incentives → Penalties

• Quality reporting is becoming more important

–Political climate to protect the public

–Patients as customers

–Business as usual; marketing

What is our incentive?

2007-2010 Ophthalmology Vascular Surgery UT Medicine

Net Collections for MedicarePart B

$2,897,390 $1,085,221 $41,612,109

PQRI Bonus % 1-5 – 2.0 % 1-5 – 2.0 % 1-5 – 2.0 %

PQRI Bonus $55,375 $20,544 $790,386

Registry: $600.00 per NPI; 10 doctors for 3 years = $18,000

PQRI MEASURE ICD-9 CODES CODE & WHEN MODIFIERS

12: Glaucoma: POAG ONHOptic Nerve Head Evaluation

365.10, 365.11365.12, 365.15

2027FDate of exam

1P: Medical8P: Unspecified

14: Macular Degeneration: DFEDilated Fundus Exam

362.50, 362.51362.52

2019FDate of exam

1P; 8P2P: Patient

18: Diabetic Retinopathy: DFESeverity of DR, CSME

362.01 – 362.06 2021FDate of exam

1P; 2P; 8P

19: Diabetic Retinopathy: PCPCommunicate DFE to PCP

362.01 – 362.06 5010F & G8397Date of exam

2P: Patient8P: Unspecified

117: Diabetes: DFEDilated Eye Exam in Diabetic Patient

250.00 - 250.93357.2, 366.41362.01 – 362.07648.00 – 648.04

2022F; 2024F2026F; 3072FDate of exam

8P: Unspecified

PQRI Measures: Ophthalmology

PQRI MEASURE ICD-9 CODES CODE & WHEN MODIFIERS

139: Cataract: Pre-Op AssessComprehensive Preoperative

66982, 6698366984

0014FDate of surgery

8P: Unspecified

140: AMD: AREDSRecommend AREDS Vitamins

362.50, 362.51362.52

4177FDate of exam

8P: Unspecified

141: POAG: IOP 15%↓ IOP by ≥ 15% or have Plan

365.10, 365.11365.12, 365.15

3284F DOS0517F & 3285F

8P: Unspecified

191: Cataract: PO VABCVA ≥20/40 in POD 1 - 90

Lens CPT Codes s comorbidities

4175FPOD 1 – 90

8P: Unspecified

192: Cataract: ComplicationsAdditional surgery in POD 1-30

N: Comp CPTsD: CE CPT code

G8627 1-30G8628 >30

124. Health Information Technology (HIT): EHRAdoption/Use of Electronic Health Records

G8447G8448

125. E-Prescribing: ≥ 1 Rx created during encounter was generated & transmitted electronically using qualified eRx system

G8553: Report 25 times during reporting period Jan 01 – Dec 31

PQRI Measures: Ophthalmology

Intervention: Encounter Form

Results

• 100 patients

• 37 patients: ≥ 1 PQRI measures apply

–Mainly DM, DR, POAG, CAT vs. AMD, E-Rx

• Physician data entry is simple with no significant impact on time

• Physician education is simple

• Sheets can be easily implemented into daily practice

No of times PQRI measures reported

24

15 15 15

10 97

1 13

24.0%

39.0%

54.0%

69.0%

79.0%

88.0%

95.0% 96.0% 97.0%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

0

10

20

30

40

50

60

70

80

90

100

2022F 2012F 5010F G3897 2027F 3284F 4175F 3285F 0517F Other

No

of

tim

es

rep

ort

ed

PQRI measures

No of times reported

PQRI Measures: Vascular

• Tobacco Use

–1000F Tobacco use assessed

• 1034 F Current tobacco smoker

• 1035F Current smokeless tobacco user

• 1036F Current tobacco non-user

–G8455 Current Tobacco User

–G8456 Current Smokeless Tobacco User

• 4000F Tobacco use cessation intervention, counseling

• 4000F Tobacco use cessation intervention RX Tx

PQRI Measures: Vascular• Current Medications

–G8427 List of current meds w/ dosages and verification

–G8430 Provider documentation that pt not eligible for med assess

–G8507 Pt not eligible for pt verification of current meds

–G8428 Documentation of current meds w/dosages w/o verification

–G8429 Incomplete or no documentation

OUTPATIENT PQRI(Vascular Surgery)

18

PQRI Claims-Based Process

Visit Documented in the Medical Record

Encounter Form Coding & Billing

Carrier/MAC

NCH

Analysis Contractor National Claims History File

Incentive Payment

Confidential Report

Critical

Step

N-365

12

109

32

1 1

31.6%

57.9%

81.6%

89.5%

94.7%97.4%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

0

5

10

15

20

25

30

35

G8427 1000F 1036F 4000F 1034F G8428 G8455

Nu

mb

er

of

CP

T co

de

s ca

ptu

red

by

EMR

CPT codes

Pareto Chart showing CPT codes documented for June 2010

0.0

68.0

258.0

95.0

-329.2 -329.2 -329.2

-485.7

-285.7

-85.7

114.3

314.3

514.3

714.3

May-10 Jun-10 Jul-10 Aug-10

Gra

nd

To

tal o

f m

eas

ure

s ca

ptu

red

Time Period

Grand Total of PQRI measures captured in the Vascular Surgery Clinic

Pre-intervention Post-intervention

Net Gain

• Vascular Medicare Collections January to June 2010

–$478,501

– 2% incentive payment - $9,570

• Total UT Medicare Collections 2009

–$14,754,638

–2% incentive payment - $295,092

Conclusions

• Currently benefit is monetary gains

• Soon to become monetary losses

• Process possible but needs complex and requires constant surveillance

• Further implementation throughout UT Medicine system