Implementing PQRI measures in Two Subspecialty Practices at UT Medicine Maureen Sheehan, M.D., Vascular Surgery Kent 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 Maureen Sheehan, MD Kent Anderson, MD, PhD Marti Pons Finance Jay Collins Administrator Susan Hilgers EPIC Edward Kennerdell UT Medicine Amruta Parekh Facilitator Andrew Krecek IT Services
CAUSE and EFFECT DIAGRAM Physicians Time Interest Consensus Mixed input Building codes IT support System Software/Hardware EMR system +/- upgrade Pharmacies not in Complex, unclear implementation instructions & directions Education Burden Coder Review Build/Transmit codes Competing Priorities Education Audit system NO PQRI Data Entry Value? Education Expense Burden Enforcement Time Staff Politics Institution
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 Medicare Part 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 Measures: Ophthalmology PQRI MEASURE ICD-9 CODES CODE & WHEN MODIFIERS 12: Glaucoma: POAG ONH Optic Nerve Head Evaluation 14: Macular Degeneration: DFE Dilated Fundus Exam 18: Diabetic Retinopathy: DFE Severity of DR, CSME 19: Diabetic Retinopathy: PCP Communicate DFE to PCP 117: Diabetes: DFE Dilated Eye Exam in Diabetic Patient 365.10, 365.11 365.12, 365.15 362.50, 362.51 362.52 2027F Date of exam 2019F Date of exam 362.01 362.06 2021F Date of exam 362.01 362.06 5010F & G8397 Date of exam 250.00-250.93 357.2, 366.41 362.01 362.07 648.00 648.04 2022F; 2024F 2026F; 3072F Date of exam 1P: Medical 8P: Unspecified 1P; 8P 2P: Patient 1P; 2P; 8P 2P: Patient 8P: Unspecified 8P: Unspecified
PQRI Measures: Ophthalmology PQRI MEASURE ICD-9 CODES CODE & WHEN MODIFIERS 139: Cataract: Pre-Op Assess Comprehensive Preoperative 140: AMD: AREDS Recommend AREDS Vitamins 141: POAG: IOP 15% IOP by 15% or have Plan 191: Cataract: PO VA BCVA 20/40 in POD 1-90 192: Cataract: Complications Additional surgery in POD 1-30 66982, 66983 66984 362.50, 362.51 362.52 365.10, 365.11 365.12, 365.15 Lens CPT Codes s comorbidities N: Comp CPTs D: CE CPT code 124. Health Information Technology (HIT): EHR Adoption/Use of Electronic Health Records 125. E-Prescribing: 1 Rx created during encounter was generated & transmitted electronically using qualified erx system 0014F Date of surgery 4177F Date of exam 3284F DOS 0517F & 3285F 4175F POD 1 90 G8627 1-30 G8628 >30 G8447 G8448 8P: Unspecified 8P: Unspecified 8P: Unspecified 8P: Unspecified G8553: Report 25 times during reporting period Jan 01 Dec 31
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 reported No of times PQRI measures reported 100 No of times reported 95.0% 96.0% 97.0% 100.0% 90 88.0% 90.0% 80 79.0% 80.0% 70 69.0% 70.0% 60 60.0% 50 54.0% 50.0% 40 39.0% 40.0% 30 20 24 24.0% 15 15 15 30.0% 20.0% 10 0 10 9 7 1 1 3 2022F 2012F 5010F G3897 2027F 3284F 4175F 3285F 0517F Other PQRI measures 10.0% 0.0%
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)
PQRI Claims-Based Process Critical Step Visit Documented in the Medical Record Encounter Form Coding & Billing N-365 NCH Analysis Contractor National Claims History File Carrier/MAC Confidential Report 18 Incentive Payment
Number of CPT codes captured by EMR Pareto Chart showing CPT codes documented for June 2010 100.0% 97.4% 94.7% 35 89.5% 90.0% 30 81.6% 80.0% 25 70.0% 57.9% 60.0% 20 50.0% 15 40.0% 10 12 31.6% 10 9 30.0% 20.0% 5 3 2 1 1 10.0% 0 G8427 1000F 1036F 4000F 1034F G8428 G8455 CPT codes 0.0%
Grand Total of measures captured 714.3 Grand Total of PQRI measures captured in the Vascular Surgery Clinic Pre-intervention Post-intervention 514.3 314.3 258.0 114.3 68.0 95.0 0.0-85.7-285.7-329.2-329.2-329.2-485.7 May-10 Jun-10 Jul-10 Aug-10 Time Period
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