2007 CMS Physician Quality Reporting Initiative (PQRI) Guidance for Reporting

Transcription

1 2007 CMS Physician Quality Reporting Initiative (PQRI) Guidance for Reporting This document is intended as an aid for submitting PQRI-eligible claims to CMS and is based on the latest information available on the CMS PQRI Web site as of May 29, 2007.

2 American College of Radiology 2

3 Table of Contents Purpose of the (User s Guidance)...5 What You Need to Know About the PQRI...5 Design of Quality Measures...6 How CMS Calculates Whether You Qualify for a Bonus...6 How Your Bonus Payout is Calculated...7 Payouts and PQRI Reporting Feedback from CMS...7 General Guidance for PQRI Reporting...7 Suggested Process from Care to Claim...7 Testing PQRI Submission on Your Billing System...8 Data-Collection Tools...8 Appendices...11 Appendix A PQRI Specifications Diagnostic Radiology Measures #10 and #11 Stroke Imaging Radiation Oncology Measures #71 and # Appendix B Successful Reporting Scenarios Attachments...27 Attachment A Sample CMS 1500 Claim Form with PQRI Data American College of Radiology 3

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5 What is the Physician Quality Reporting Initiative (PQRI)? Enacted by Congress in December 2006, the Physician Quality Reporting Initiative (PQRI) is the first attempt by the Centers for Medicare and Medicaid Services (CMS) to move toward a quality-based system of physician reimbursement. This program will be implemented during the last six months of Experimental in nature, the goal of the PQRI is two-fold: physicians will become accustomed to reporting quality data and they will be offered a bonus for doing so. The PQRI does not evaluate physician performance; rather, it simply rewards physicians for submitting claims that include data related to quality of care. Participation in the PQRI is completely voluntary. Physicians who participate in the PQRI and meet minimum reporting requirements will receive a bonus. Non-participants will continue to receive their regular reimbursement under the Medicare Physician Fee Schedule. Currently, 74 quality measures (QMs) are included in the PQRI, which represent a wide array of specialties; of these, two relate to diagnostic radiologists and two relate to radiation oncologists (#10 and #11; #71 and #74, respectively see Appendix A). For interventional radiologists, up to five QMs may relate to your practice (#20 24 on the CMS QM list). You will need to look at these measures CPT coding specifications to make sure you perform a PQRI-eligible procedure. Please keep in mind that, if there are four or more QMs applicable to your practice (which might also include #s 10 and 11 if you perform stroke-related imaging), to qualify for the bonus, you must report on at least 3 QMs. If only 3 QMs apply to your practice, you must report on all three. Purpose of the CMS PQRI Reporting Guidance (User s Guidance) The purpose of this User s Guidance is to make participation in CMS s Physician Quality Reporting Initiative simple for ACR members. Participation only requires that you submit claims that have the correct ICD-9, CPT-I, and CPT-II codes that are specified for a particular PQRI quality measure. Compared to coding regular Medicare claims, the only added step is to include the new CPT-II codes. Each code indicates whether a particular service or procedure was provided to a qualifying patient. What You Need to Know About the PQRI 1. Participation is voluntary; no enrollment is required. Submission of claims with PQRIrelated codes triggers CMS to count each claim toward meeting minimum reporting requirements for receiving a PQRI bonus. All PQRI claims must be dated for service between July 1 and Dec. 31, 2007 (The deadline for CMS receipt of these claims is Feb. 29, 2008.) 2. Physician performance is not being evaluated; the bonus is paid simply for reporting a practice's appropriate quality measures (QMs). This applies even in cases where all or some of a QM's clinical requirements have not been met. So, even if the action American College of Radiology 5

6 described in a measure is not performed in an eligible case, a claim can be counted toward the reporting requirements. 3. The size of your bonus payout depends on the volume of valid PQRI-related claims submitted to your carrier (subject to a statutory cap). To maximize the PQRI bonus, radiologists should maximize the number of valid PQRI claims they submit. 4. To qualify for a bonus, you must report on at least three QMs (if less than three exist that apply to your scope of practice, you must report each measure that is applicable) and submit claims with CPT-II quality codes for 80 percent of all qualifying patients. To be counted by CMS, the CPT-II code(s) must appear on the same claim as the appropriate ICD-9 and CPT-I codes. 5. For participating diagnostic radiologists and radiation oncologists to qualify for the PQRI bonus, you must report on both of the two QMs related to your practice (#10 and #11; #71 and #74, respectively see Appendix A), and report on at least 80 percent of all cases that apply to each of the two measures. Design of Quality Measures Every QM in the PQRI allows calculation of the percentage of cases where a qualified provider performs a clinically indicated service or procedure. As such, a QM is represented as a ratio: The denominator* counts all patients who should receive the indicated service or procedure (based on appropriate ICD-9, CPT-I codes, and patient demographics). The numerator counts all patients for whom this service or procedure is actually performed or not performed (using appropriate CPT-II codes). *The underlying expectation is that the indicated service or procedure should be performed for all patients counted in the denominator. CMS provides special CPT-II modifiers to allow exclusion of certain patients from the denominator, or to indicate when a service/procedure is not performed. CMS bases PQRI bonuses on a provider s rate of reporting PQRI-related data, and not on the actual performance of any clinically indicated services or procedures. The PQRI s goal is to acclimate providers to submitting quality-related data to CMS. CMS will meanwhile gain insight toward designing a performance-based system of reimbursement in the future. How CMS Calculates Whether You Qualify for a Bonus CMS will count each claim you submit with an ICD-9 and CPT-I code matching the specifications for a particular PQRI QM toward your total patient population for whom the QM applies (denominator). CMS also counts how many times you submit an appropriate CPT-II code (numerator) on the same claims. For each QM applicable to your practice, there must be a CPT-II code on at least 80 percent of the claims with the related ICD-9 and CPT-I codes, to meet the minimum reporting requirement for bonus eligibility. Once CMS has received all claims for the period July 1 Dec. 31, 2007, it will calculate each QM applicable to your practice and whether you have met the 80 percent minimum reporting requirement. American College of Radiology 6

7 How Your Bonus Payout is Calculated When the 80 percent minimum reporting requirement is met, CMS will then calculate your bonus payout. It will be the lesser of 1.5 percent of your total allowable Medicare charges for the above period, or a special cap formula, which is meant to encourage a sufficient volume of PQRI reporting. To receive the maximum bonus possible for your practice, you should submit as many valid PQRI claims as possible. CMS will calculate bonuses at the individual physician level and aggregate all bonuses under a single taxpayer identification number for payout. Payouts and PQRI Reporting Feedback from CMS CMS will send out all PQRI payouts and individual physician reporting and performance rate profiles in mid Physician-specific profile data is confidential and is not provided to the public. General Guidance for PQRI Reporting All PQRI reporting is claims based and may be submitted via the paper-based CMS 1500 claims form or the electronic 837-P claims form. Key reminders for filling out these forms: CPT-II quality-data codes are used for reporting the two diagnostic radiology QMs (stroke measures); G-codes are used for the radiation oncology measures. Submitted charge field cannot be left blank; CPT-II and G-codes are reported with a $0.00 charge (or charge of a small amount if billing software does not accept $0.00). Do not forget to include the charge for the service/procedure (i.e., include the category I code and charge amount)! To be counted by CMS, the appropriate CPT-II code(s) or G-codes must be reported on the same claim as the patient diagnosis (ICD-9) and service (CPT-I) codes. Claims that are resubmitted only to add CPT Category II or G-codes will not be included in the analysis and will not count toward bonus calculation. No monies can be collected from beneficiaries for quality-data codes. Suggested Process from Care to Claim: 1. Patient is identified by office staff or physicians as eligible for PQRI reporting, based on clinical condition and demographics. 2. Document in medical record that patient is eligible for reporting and that this claim should be quality coded. 3. Data can be collected on American Medical Association (AMA) PQRI Data Collection Worksheets (See Attachment A). 4. Coding staff enter quality-code data on claims in same location as other Healthcare Common Procedure Coding System (HCPCS) code reporting: 837 Electronic Claims: SV1 Professional Service segment of the 2400 Service Line loop, SV101-1, SV101-2, or CMS 1500: Field 24D. American College of Radiology 7

8 5. Please remember to include the National Provider Identifier (NPI) on the claim form! Analysis will be performed by individual NPI under each Taxpayer Identification Number (TIN). Participating professionals must use the correct individual NPIs. The analysis required by statute requires that the individual providers be identified on the claims. Providers who bill to more than one TIN will have a separate analysis for each TIN. Testing PQRI Submission on Your Billing System Eligible professionals interested in testing the readiness of their billing system for PQRI quality data-code reporting will have a chance to do so prior to July 1, CMS has posted information on how to test your billing system. The G8300 code can be used to test readiness as shown below, if used before July 1, 2007, at which point it will be retired. 1. Add the G8300 test code as a line item on any claims for services. On the ASC X12N health-care claim transaction (version 4010A1), submit the HCPCS code G8300 in the SV101-2 "Product/Service ID" Data Element on the SV1 "Professional Service" Segment of the 2400 "Service Line" Loop. It is also necessary to identify in this segment that a HCPCS code is being supplied by submitting the HC in data element SV101-1 within the SV1 "Professional Service" Segment. For claims submitted on the CMS 1500 Form, report the test code in field 24D. 2. Randomly enter $0.00 or $0.01 as the line item charge for the test code. This will confirm the ability of billing software or clearinghouses to accept either. 3. Check your Remittance Advice (RA) for these claims to assure the test code has been passed through and processed by the carrier or MAC. You should see Claim Adjustment Reason Code message 96, Non-covered charge(s). Also, you will see Remittance Advice Remark Code message N365, This procedure code is not payable. It is for reporting/information purposes only. The RA will serve as your feedback for the test. CMS will not issue any other feedback. 4. The RA will indicate that the test code was denied. The test code will also show up on the beneficiary s MSN with the statement, This code is for informational/reporting purposes only. You should not be charged for this code. If there is a charge, you do not have to pay the amount. This same message will appear on MSNs during the 2007 PQRI reporting period for designated 2007 PQRI codes. You are free to test until July 1. Data-Collection Tools Your practice may want to develop its own data-collection tools; however, the AMA has created simple, easily understood instructions and sheets to help you through the process. These American College of Radiology 8

9 will be available on the AMA and CMS PQRI Web sites ( and The data-collection sheets are designed to assist in gathering of Quality Measure (QM) data at the time of the patient procedure or visit. The radiologist can record the information by checking the corresponding boxes on the collection sheets, which provides the necessary billing information to append the appropriate CPT-II codes to the CMS 1500 (or electronic 837) claim form, along with the usual CPT and ICD-9 codes. The form can be inserted into the chart at check-in or by other personnel at a time convenient in the care delivery process. To ensure that all eligible cases are reported, the information needs to be made available to the coder when the bill is prepared for submission. It is most important that you devise a system to identify eligible cases, record the needed information, and get it onto the claim. Please keep in mind that it is necessary to record and submit one or more CPT-II or G-codes on the claim form for each eligible CPT-I procedure billed. Please note that, for Measure #10, two CPT-II quality data codes may be needed to be recorded for one procedure; in that case, the CPT/HCPCS coding for one procedure may take up three lines or more. For example: a patient received a CT, head or brain, without contrast (CPT 70450) and the procedure was performed within 24 hours of arrival at the hospital (CPT II 3111F), and presence or absence American College of Radiology 9

10 of hemorrhage and mass lesion and acute infarction is documented in the procedure final report (CPT II 3110F). All three codes need to be included in Section 24 of the CMS Page intentionally left blank. American College of Radiology 10

11 Appendices American College of Radiology 11

12 Appendix A PQRI Specifications Diagnostic Radiology Measures #10 and #11 Stroke Imaging Radiation Oncology Measures #71 and #74 Measure #10: Stroke and Stroke Rehabilitation: Computed Tomography (CT) or Magnetic Resonance Imaging (MRI) Reports DESCRIPTION Percentage of final reports for CT or MRI studies of the brain performed within 24 hours of arrival to the hospital for patients aged 18 years and older, with the diagnosis of ischemic stroke, TIA, or intracranial hemorrhage that include documentation of the presence or absence of each of the following: hemorrhage and mass lesion and acute infarction. INSTRUCTIONS This measure is to be reported each time a CT or MRI is performed in a hospital or outpatient setting during the reporting period for patients with a diagnosis of ischemic stroke, TIA, or intracranial hemorrhage. It is anticipated that clinicians who provide the physician component of diagnostic imaging studies for patients with stroke or TIA in the hospital or outpatient setting will submit this measure. This measure can be reported using CPT Category II codes. ICD-9 diagnosis codes, CPT procedure codes, and patient demographics (age, gender, etc.) are used to identify patients who are included in the measure s denominator. CPT Category II codes are used to report the numerator of the measure. When reporting the measure, submit the listed ICD-9 diagnosis codes, CPT procedure codes, and the appropriate CPT Category II code or the CPT Category II code with the modifier. The modifier allowed for this measure is: 8P: reasons not otherwise specified. There are no allowable medical (1P), patient (2P), or system (3P) exclusions for this measure. NUMERATOR: Final reports of the CT or MRI that include documentation of the presence or absence of each of the following: hemorrhage and mass lesion and acute infarction. Definition: Equivalent terms or synonyms for hemorrhage, mass lesion, or infarction, if documented in the CT or MRI report, would meet the measure. Numerator Coding: Presence/Absence of Hemorrhage, Mass Lesion, and Acute Infarction Documented: CPT II 3110F: Presence or absence of hemorrhage,mass lesion, and acute infarction documented in final CT or MRI report American College of Radiology 12

13 AND CPT II 3111F: CT or MRI of the brain performed within 24 hours of arrival to the hospital OR If patient does not meet denominator inclusion because CT or MRI of the brain was performed greater than 24 hours after arrival to the hospital, report: CPT II 3112F: CT or MRI of the brain performed greater than 24 hours after arrival to the hospital OR Presence/Absence of Hemorrhage, Mass Lesion, and Acute Infarction not Documented, Reason Not Specified Append a reporting modifier (8P) to CPT Category II code 3110F to report circumstances when the action described in the numerator is not performed, and the reason is not otherwise specified. AND 8P: Presence or absence of hemorrhage and mass lesion and acute infarction was not documented in final CT or MRI report, reason not otherwise specified CPT II 3111F: CT or MRI of the brain within 24 hours of arrival to the hospital DENOMINATOR: All final reports for CT or MRI studies of the brain performed within 24 hours of arrival to the hospital for patients aged 18 years and older, with an admitting diagnosis of ischemic stroke,tia, or intracranial hemorrhage Denominator Coding: An ICD-9 diagnosis code to identify patients with a diagnosis of ischemic stroke,tia, or intracranial hemorrhage and a CPT procedure code for patients undergoing CT or MRI of the brain are required for denominator inclusion. ICD-9 diagnosis codes: 431, , , , , , , , , , , 435.8, 435.9, AND CPT procedure codes with or without Modifier 26 to specify physician component: 70450, 70460, 70470, , 0042T American College of Radiology 13

14 RATIONALE: The CT and MRI findings are critical to initiating care for the patient with stroke. All CT and MRI reports should address the presence or absence of these three important findings. This documentation is particularly vital in the report of the first imaging study performed after arrival at the hospital, on which initial treatment decisions will be based. CLINICAL RECOMMENDATION STATEMENTS: Brain imaging is required to guide acute intervention. (Grade A) There is a uniform agreement that CT accurately identifies most cases of intracranial hemorrhage and helps discriminate nonvascular causes of neurological symptoms, e.g., brain tumor. (Grade B) With the advent of rtpa treatment, interest has grown in using CT to identify subtle, early signs of ischemic brain injury (early infarct signs) or arterial occlusion that might affect decisions about treatment. The presence of these signs is associated with poor outcomes. (Adams, ASA, 2003) (Class A) A technically adequate head CT scan is required prior to administration of thrombolytic therapy to exclude brain hemorrhage and nonischemic diagnoses. The baseline CT scan is also sensitive for detection of early signs of cerebral infarction. Subtle or limited signs of early infarction on the CT scan are common even within the first 3 hours of stroke evolution. Preliminary data suggest that specific MRI profiles may identify patients who are particularly likely to benefit from thrombolytic therapy. New MRI techniques including perfusionweighted and diffusion-weighted may detect ischemic injury in the first hour and may reveal the extent of reversible and irreversible injury. In addition, MRI appears to be highly sensitive for identification of acute brain hemorrhage. (Albers, ACCP, 2004) American College of Radiology 14

15 Measure #11: Stroke and Stroke Rehabilitation: Carotid Imaging Reports DESCRIPTION: Percentage of final reports for carotid imaging studies (neck MR angiography [MRA], neck CT angiography [CTA], neck duplex ultrasound, carotid angiogram) performed for patients aged 18 years and older, with the diagnosis of ischemic stroke or TIA that include direct or indirect reference to measurements of distal internal carotid diameter as the denominator for stenosis measurement. INSTRUCTIONS: This measure is to be reported each time a carotid imaging study is performed during the reporting period for patients with a diagnosis of ischemic stroke or TIA. It is anticipated that clinicians who provide the physician component of diagnostic imaging studies for patients with stroke or TIA in the hospital or outpatient setting will submit this measure. This measure can be reported using CPT Category II codes: ICD-9 diagnosis codes, CPT procedure codes, and patient demographics (age, gender, etc.) are used to identify patients who are included in the measure s denominator. CPT Category II codes are used to report the numerator of the measure. When reporting the measure, submit the listed ICD-9 diagnosis codes, CPT procedure codes, and the appropriate CPT Category II code or the CPT Category II code with the modifier. The modifiers allowed for this measure are: 1P- medical reasons, 8P reasons not otherwise specified. NUMERATOR: Final carotid imaging study reports that include direct or indirect reference to measurements of distal internal carotid diameter as the denominator for stenosis measurement. Definition: Direct or indirect reference to measurements of distal internal carotid diameter as the denominator for stenosis measurement includes direct angiographic stenosis calculations based on the distal lumen as the denominator for stenosis measurement or an equivalent validated method referenced to the above method (e.g., for duplex ultrasound studies, velocity parameters that correlate the residual internal carotid lumen with methods based on the distal internal carotid lumen). Numerator Coding: Reference to Measurements of Distal Internal Carotid Diameter as the Denominator for Stenosis Measurement Documented CPT II 3100F: Carotid image study report includes direct or indirect reference to measurements of distal internal carotid diameter as the denominator for stenosis measurement OR American College of Radiology 15

16 Measurements of Distal Internal Carotid Diameter not Referenced for Medical Reasons Append a modifier (1P) to CPT Category II code 3100F to report documented circumstances that appropriately exclude patients from the denominator. OR 1P: Documentation of medical reason(s) for not including direct or indirect reference to measurements of distal internal carotid diameter Measurements of Distal Internal Carotid Diameter not Referenced, Reason Not Specified Append a reporting modifier (8P) to CPT Category II code 3100F to report circumstances when the action described in the numerator is not performed and the reason is not otherwise specified. 8P: Carotid image study report did not include direct or indirect reference to measurements of distal internal carotid diameter as the denominator for stenosis measurement, reason not otherwise specified DENOMINATOR: All final reports for carotid imaging studies (neck MR angiography [MRA], neck CT angiography [CTA], neck duplex ultrasound, carotid angiogram) performed for patients aged 18 years and older with a diagnosis of ischemic stroke or TIA. Denominator Coding: An ICD-9 diagnosis code to identify patients with a diagnosis of ischemic stroke or TIA and a CPT procedure code for patients undergoing carotid imaging are required for denominator inclusion. ICD-9 diagnosis codes: , , , , , , , , , , 435.8, 435.9, AND CPT procedure codes with or without Modifier 26 to specify physician component: , 70498, 75660, 75662, 75665, 75671, 75676, 75680, 93880, RATIONALE: Since the clinical decision-making is based on randomized trial evidence, and degree of stenosis is an important element of the decision for carotid intervention, characterization of the degree of stenosis needs to be standardized. Requiring that stenosis calculations be based on a denominator of distal internal carotid diameter or, in the case of duplex ultrasound, velocity measurements that have been correlated to angiographic stenosis calculations based on distal internal carotid diameter makes the measure applicable to both imaging and duplex studies. American College of Radiology 16

17 CLINICAL RECOMMENDATION STATEMENTS: For patients with symptomatic atherosclerotic carotid stenosis greater than 70 percent, as defined using the NASCET criteria, the value of carotid endarterectomy (CEA) has been clearly established from the results of 3 major prospective randomized trials: the NASCET, the European Carotid Surgery Trial (ECST), and the Veterans Affairs Cooperative Study Program. Among symptomatic patients with TIAs or minor strokes and high-grade carotid stenosis, each trial showed impressive relative and absolute risk reductions for those randomized to surgery. For patients with carotid stenosis less than 50 percent, these trials showed that there was no significant benefit of surgery. (Sacco, ASA, 2006) It is important to consider that the degree of carotid stenosis in ECST was measured differently than that in NASCET. The degree of carotid stenosis is significantly higher if calculated by the NASCET rather than the ECST method. In summary, it appears that patients with a recent TIA or nondisabling stroke with ipsilateral carotid stenosis benefit from surgery if the stenosis is greater than 50 percent as measured by the NASCET method; however, this benefit appears to be less pronounced in women. Recently symptomatic patients with greater than 70 percent stenosis as measured by the NASCET method can expect a far greater benefit from carotid endarterectomy. (Albers, AHA, 1999) American College of Radiology 17

18 Measure #74: Radiation Therapy Recommended for Invasive Breast Cancer Patients Who Have Undergone Breast Conserving Surgery DESCRIPTION: Percentage of invasive female breast cancer patients aged 18 through 70 years old, who have undergone breast-conserving surgery and who have received recommendation for radiation therapy within 12 months of the first office visit. INSTRUCTIONS: This measure is to be reported a minimum of once per reporting period for female breast cancer patients at the time of the initial office visit. It is anticipated that clinicians who care for patients with invasive breast cancer and radiation therapy will submit this measure. This measure is reported using G-codes: ICD-9 diagnosis codes, CPT E/M service codes, and patient demographics (age, gender, etc.) are used to identify patients who are included in the measure s denominator. G-codes are used to report the numerator of the measure. When reporting the measure, submit the appropriate ICD-9 diagnosis codes, CPT E/M service codes, and the appropriate G-code. NUMERATOR: Female patients with invasive breast cancer aged 18 to 70 years old who have undergone breast-conserving surgery and who then receive recommendation for radiation therapy within 12 months of the first office visit. Numerator Instruction: The numerator code should be reported at the time of radiation therapy services. Definitions: Radiation therapy may include external beam radiation or brachytherapy. Numerator Coding: Radiation Therapy Recommended G8379: Documentation of radiation therapy recommended within 12 months of first office visit OR Radiation Therapy Not Recommended for Documented Reasons G8378: Clinician documentation that patient was not an eligible candidate for radiation therapy measure OR Radiation Therapy Not Recommended American College of Radiology 18

19 G8383: No documentation of radiation therapy recommended within 12 months of first office visit DENOMINATOR: All female patients aged 18 to 70 years with invasive breast cancer Denominator Coding: An ICD-9 diagnosis code to identify patients with a diagnosis of invasive breast cancer and a CPT E/M service code are required for denominator inclusion. ICD-9 diagnosis codes: 174.0, 174.1, 174.2, 174.3, 174.4, 174.5, 174.6, 174.8, AND CPT E/M service codes: 99241, 99242, 99243, 99244, RATIONALE: Data from multiple large randomized trials have demonstrated that the addition of radiation after breast conserving surgery in patients with invasive breast cancer lowers the risk of local recurrence. The Oxford meta-analysis of these studies (Peto, et. al., Lancet, 2006) has also detected an improvement in overall survival with the use of radiation therapy in this setting. CLINICAL RECOMMENDATION STATEMENTS: National Comprehensive Cancer Network Breast Cancer guideline recommendations v2.2006, BINV-2. can be found at The National Quality Forum is in the process of approving the National Voluntary Consensus Standards for Diagnosis and Treatment of Breast and Colon Cancer, which includes a measure at the facility level for radiation therapy for patients who have had breast-conserving surgery for accountability purposes. American College of Radiology 19

20 Measure #71: Hormonal Therapy for Stage IC-III, ER/PR Positive Breast Cancer DESCRIPTION: Percentage of Stage IC-III, estrogen receptor (ER) or progesterone receptor (PR) positive, female breast-cancer patients aged 18 years and older who are receiving tamoxifen or aromatase inhibitor (AI) at the time of the visit. INSTRUCTIONS: This measure is to be reported a minimum of once per reporting period for all female breastcancer patients seen during the reporting period. It is anticipated that clinicians who treat patients with breast cancer will submit this measure. The reporting clinician is not required to have written the initial prescription. This measure is reported using G-codes: ICD-9 diagnosis codes, CPT E/M service codes, and patient demographics (age, gender, etc.) are used to identify patients who are included in the measure s denominator. G-codes are used to report the numerator of the measure. When reporting the measure, submit the listed ICD-9 diagnosis codes, CPT E/M service codes, and the appropriate G-code. NUMERATOR: Patients receiving tamoxifen or AIs and have Stage 1C-III, ER/PR positive breast cancer Numerator Coding: Tamoxifen or Aromatase Inhibitor Documented or Prescribed G8381: For patients with ER or PR positive, Stage IC-III breast cancer, clinician documented or prescribed that the patient is receiving tamoxifen or aromatase inhibitor OR Tamoxifen or Aromatase Inhibitor not Documented or Prescribed for Documented Reasons G8376: Clinician documentation that breast-cancer patient was not eligible for tamoxifen or aromatase inhibitor therapy measure OR Tamoxifen or Aromatase Inhibitor not Documented or Prescribed G8380: For patients with ER or PR positive, Stage IC-III breast cancer, clinician did not document that the patient received or was prescribed tamoxifen or aromatase inhibitor American College of Radiology 20

21 DENOMINATOR: All female patients aged 18 years and older with breast cancer Denominator Coding: An ICD-9 diagnosis code to identify patients with a diagnosis of breast cancer and a CPT E/M service code are required for denominator inclusion. AND ICD-9 diagnosis codes: 174.0, 174.1, 174.2, 174.3, 174.4, 174.5, 174.6, 174.8, CPT E/M service codes: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99218, 99219, 99220, 99221, 99222, 99223, 99231, 99232, 99233, 99234, 99235, 99236, 99241, 99242, 99243, 99244, 99245, 99251, 99252, 99253, 99254, RATIONALE: Based on results from multiple large randomized trials, adjuvant therapy for women with hormone receptor-positive breast cancer should include hormonal therapy in order to lower the risk of tumor recurrence. CLINICAL RECOMMENDATION STATEMENTS: American Society of Clinical Oncology, Use of Aromatase Inhibitors As Adjuvant Therapy for Postmenopausal Women With Hormone Receptor-Positive Breast Cancer can be found at nextoid=e64ef314170d8010vgnvcm100000ed730ad1rcrd&vgnextfmt=default National Comprehensive Cancer Network Breast Cancer guideline recommendations for stage ICIII, ER/PR positive cancer: BINV-G, BINV-5, BINV-6, BINV-9 can be found at American College of Radiology 21

22 Appendix B Successful Reporting Scenarios PQRI Measure # 10 Stroke CT/MRI Reports Mr. Hayes has diagnosis of ischemic stroke, TIA or intracranial hemorrhage* Situation 1: Situation 2: Mr. Hayes brain study was performed greater than 24 hours after arrival at hospital CPT II code 3112F Mr. Hayes brain study is performed within 24 hours arrival at hospital CPT II code 3111F AND Dr. Simms documents presence or absence of hemorrhage and mass lesion and acute infarction in the brain study final report CPT II code 3110F Situation 3: Mr. Hayes brain study is performed within 24 hours arrival at hospital CPT II code 3111F AND Dr. Simms does not document presence or absence of hemorrhage and mass lesion and acute infarction in the brain study final report CPT II code 3110F-8P All of these situations represent successful 2007 PQRI reporting for Measure #10. * Valid ICD-9 codes: 431, , , , , , , , , , , 435.8, 435.9, ** Valid CPT codes: 70450, 70460, 70470, , 0042T American College of Radiology 22

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24 PQRI Measure # 11 Stroke Carotid Imaging Reports Mr. Hayes has diagnosis of ischemic stroke, TIA or intracranial hemorrhage* Mr. Hayes has a carotid imaging study read by Dr. Simms** Situation 1: Situation 2: In final report of Mr. Hayes carotid imaging study Dr. Simms makes note that all carotid stenosis measurements are in conformance with In final report of Mr. Hayes carotid imaging study Dr. Simms documents a medical reason for not using a NASCET-type methodology for stenosis measurement Situation 3: In final report of Mr. Hayes carotid imaging study Dr. Simms does not note that a NASCET-type methodology was used for carotid stenosis measurements NASCET-type methodology CPT II code 3100F-1P CPT II code 3100F-8P CPT II code 3100F All of these situations represent successful 2007 PQRI reporting for Measure #11. * Valid ICD-9 codes: , , , , , , , , , , 435.8, 435.9, ** Valid CPT codes: , 70498, 75660, 75662, 75665, 75671, 75676, 75680, 93880, American College of Radiology 24

25 PQRI Measure # 74 Radiation Therapy Recommended for Invasive Breast Cancer Patients Who Have Undergone Breast Conserving Surgery Ms. Thomas, 20 years of age, has diagnosis of invasive breast cancer* Ms. Thomas has had an initial office visit following breast conserving surgery.** Situation 1: Situation 2: Situation 3: Following breast conservation surgery it was determined and documented that Ms. Thomas is not an eligible candidate for radiation therapy. G8378 Ms. Thomas received a recommendation for radiation therapy within 12 months of her initial office visit following breast conserving surgery. G8379 There is no documentation that Ms. Thomas received a recommendation for radiation therapy within 12 months of her initial office visit following breast conserving surgery. G8383 All of these situations represent successful 2007 PQRI reporting for Measure #11. * Valid ICD-9 codes: 174.0, 174.1, 174.2, 174.3, 174.4, 174.5, 174.6, 174.8, ** Valid CPT E/M codes: 99241, 99242, 99243, 99244, American College of Radiology 25

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27 Attachments Attachment A Sample CMS 1500 Claim Form with PQRI Data American College of Radiology 27