Transcript The ABC’s of PQRI - American Medical Directors Association

The ABC’s of PQRI
in the SNF/NF setting
The ABC’s of PQRI
• Presented @ Carolinas Medical Directors
Assn. conference 10/9/2009
• Rod Baird – presenter
– President of Geriatric Practice Management,
Inc. Asheville, NC. [email protected]
– Mr. Baird reports no conflict of interest
associated with this presentation
Origin of PQRI
• The 2006 Tax Relief and Health Care Act
required the establishment of a physician
quality reporting system, including an
incentive payment for eligible
professionals who satisfactorily report data
on quality measures for covered services
furnished to Medicare beneficiaries. CMS
named this program the Physician Quality
Reporting Initiative (PQRI).
PQRI
• CMS – Medicare incentive program
• Began in 2007 w/ 1.5% payment for
successful participation
• Incentive increased to 2% in 2009
• Proposed to continue in 2010
• 2010 data will serve as basis for public
reporting of MD ‘quality’
What is a PQRI Measure
• Intent – to promote individual quality
improvement
• Measure types (process, outcome, etc.)
• Subject population (age, diagnosis, etc.)
– Exclusions from subject population
• A specification (what is measured)
– Frequency (annually, each encounter, etc,)
• Location (specified by CPT or HCPCS)
Measure Example
Measure #1: Hemoglobin A1c Poor Control in
Type 1 or 2 Diabetes Mellitus
• Reporting Description: Percentage of patients aged
18 through 75 years with diabetes and an applicable
CPT Category II code reported a minimum of once
during the reporting period
• Performance Description: Percentage of patients
aged 18 through 75 years with diabetes (type 1or type 2)
who had most recent hemoglobin A1c greater than 9.0%
PQRI in the Nursing Facility
• No measures are specific to LTC setting
• 24 measures apply to LTC CPT Codes
• A measure’s definition of ‘quality’ may not
match ‘best practices’ for the LTC
population.
• Neither AMDA or AGS have proposed
PQRI measures, nor published any
guidance on their use.
PQRI Participation
• Claims Based
– Individual
– Measure Group
• Registry
– Measure Group
Claims Based -Individual
• Submit individual measures on claims
– 24 measures apply to 99304-99310 codes
• You must use a minimum of 3 measures in 80% of
the eligible encounters (e.g. annual or each visit).
• Some measures apply to nearly every patient in a
nursing home
– #47 Advanced Care Plan (≥ 65 y/o, and 99304-99310)
• Others are highly restrictive
– #12 Primary Open Angle Glaucoma (POAG): Optic
Nerve Evaluation
» patients aged ≥18 y/o with POAG who have an optic nerve
head evaluation during one or more office visits within 12
months
LTC APPLICABLE
PQRI MEASURES
for 2009
2010 not published
1
Diabetes Mellitus: Hemoglobin A1c Poor Control in Diabetes Mellitus
Percentage of patients aged 18 through 75 years with diabetes mellitus who had mostrecent
hemoglobin A1c greater than 9.0%
2
Diabetes Mellitus: Low Density Lipoprotein (LDL-C) Control in Diabetes Mellitus
Percentage of patients aged 18 through 75 years with diabetes mellitus who had most recent LDL-C
level in control (less than 100 mg/dl)
3
Diabetes Mellitus: High Blood Pressure Control in Diabetes Mellitus
Percentage of patients aged 18 through 75 years with diabetes mellitus who had most recent blood
pressure in control (less than 140/80 mmHg)
5
Heart Failure: Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin
Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD)
Percentage of patients aged 18 years and older with a diagnosis of heart failure and LVSD who were
prescribed ACE inhibitor or ARB therapy
6
Coronary Artery Disease (CAD): Oral Antiplatelet Therapy Prescribed for Patients
with CAD
Percentage of patients aged 18 years and older with a diagnosis of CAD who were prescribed oral
antiplatelet therapy
7
Coronary Artery Disease (CAD): Beta-Blocker Therapy for CAD Patients with Prior
Myocardial Infarction (MI)
Percentage of patients aged 18 years and older with a diagnosis of CAD and prior MI who were
prescribed beta-blocker therapy
8
Heart Failure: Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)
Percentage of patients aged 18 years and older with a diagnosis of heart failure who also have LVSD
and who were prescribed beta-blocker therapy
12
Primary Open Angle Glaucoma (POAG): Optic Nerve Evaluation
Percentage of patients aged 18 years and older with a diagnosis of POAG who have an optic nerve
head evaluation during one or more office visits within 12 months
14
Age-Related Macular Degeneration (AMD): Dilated Macular Examination
Percentage of patients aged 50 years and older with a diagnosis of AMD who had a dilated macular examination
performed which included documentation of the presence or absence of macular thickening or hemorrhage AND the level
of macular degeneration severity during one or more office visits within 12 months
18
Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level of Severity of
Retinopathy
Percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or
fundus exam performed which included documentation of the level of severity of retinopathy and the presence or absence
of macular edema during one or more office visits within 12 months
19
Diabetic Retinopathy: Communication with the Physician Managing On-going Diabetes Care
Percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or
fundus exam performed with documented communication to the physician who manages the on-going care of the patient
with diabetes mellitus
regarding the findings of the macular or fundus exam at least once within 12 months
47
Advance Care Plan
Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in
the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not
wish or
was not able to name a surrogate decision maker or provide an advance care plan
110
Preventive Care and Screening: Influenza Immunization for Patients ≥ 50 Years Old
Percentage of patients aged 50 years and older who received an influenza immunization during the flu season (September
through February)
Preventive Care and Screening: Colorectal Cancer Screening
Percentage of patients aged 50 through 80 years who received the appropriate colorectal cancer screening
113
Diabetes Mellitus: Dilated Eye Exam in Diabetic Patient
Percentage of patients aged 18 through 75 years with a diagnosis of diabetes mellitus who had a dilated eye exam
117
118
Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor
Blocker (ARB) Therapy for Patients with CAD and Diabetes and/or Left Ventricular Systolic Dysfunction (LSVD)
Percentage of patients aged 18 years and older with a diagnosis of CAD who also have diabetes mellitus and/or LVSD
who were prescribed ACE inhibitor or ARB therapy
119
Diabetes Mellitus: Urine Screening for Microalbumin or Medical Attention for
Nephropathy in Diabetic Patients
Percentage of patients aged 18 through 75 years with diabetes mellitus who received urine protein screening or
medical attention for nephropathy during at least one office visit within 12 months
126
Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy –
Neurological Evaluation
Percentage of patients aged 18 years and older with a diagnosis of diabetes mellitus who
had a neurological examination of their lower extremities within 12 months
127
Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention – Evaluation of Footwear
Percentage of patients aged 18 years and older with a diagnosis of diabetes mellitus who were evaluated for
proper footwear and sizing
140
Age-Related Macular Degeneration (AMD): Counseling on Antioxidant Supplement
Percentage of patients aged 50 years and older with a diagnosis of AMD and/or their caregiver(s) who were
counseled within 12 months on the benefits and/or risks of the Age-Related Eye Disease Study (AREDS)
formulation for preventing progression of AMD
141
Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by
15% OR Documentation of a Plan of Care
Percentage of patients aged 18 years and older with a diagnosis of POAG whose glaucoma treatment has not
failed (the most recent IOP was reduced by at least 15% from the pre-intervention level) OR if the most recent
IOP was not reduced by at least 15% from the pre-intervention level, a plan of care was documented within 12
months
152
Coronary Artery Disease (CAD): Lipid Profile in Patients with CAD
Percentage of patients aged 18 years and older with a diagnosis of CAD who received least one lipid profile
within 12 months
154
Falls: Risk Assessment
Percentage of patients aged 65 years and older with a history of falls who had a risk assessment for falls
completed within 12 months
163
Diabetes Mellitus: Foot Exam
The percentage of patients aged 18 through 75 years with diabetes who had a foot examination
MEASURE GROUPS
• Diabetes Mellitus Measures Group
– DM is only measures group applicable to CPT 99304-99318
• Chronic Kidney Disease (CKD) Measures
Group
• Preventive Care Measures Group
• Rheumatoid Arthritis Measures Group
• Perioperative Care Measures Group
• Back Pain Measures Group
Diabetes Mellitus Measures Group:
#1. Hemoglobin A1c Poor Control in Diabetes Mellitus
Percentage of patients aged 18 through 75 years with diabetes mellitus who had most recent
hemoglobin A1c greater than 9.0%
#2. Low Density Lipoprotein Cholesterol (LDL-C) Control in Diabetes Mellitus
Percentage of patients aged 18 through 75 years with diabetes mellitus who had most recent LDLC level in control (less than 100 mg/dL)
#3. High Blood Pressure Control in Diabetes Mellitus
Percentage of patients aged 18 through 75 years with diabetes mellitus who had most recent blood
pressure in control (less than 140/80 mmHg)
#117. Dilated Eye Exam in Diabetic Patient
Percentage of patients aged 18 through 75 years with a diagnosis of diabetes mellitus who had a
dilated eye exam
#119. Urine Screening for Microalbumin or Medical Attention for Nephropathy in Diabetic
Patients
Percentage of patients aged 18 through 75 years with diabetes mellitus who received urine protein
screening or medical attention for nephropathy during at least one office visit within 12 months
#163. Foot Exam
Percentage of patients aged 18 through 75 years with diabetes mellitus who had a foot examination
Diabetes Mellitus Measures Group – required steps to successfully report:
#1. Hemoglobin A1c Poor Control in Diabetes Mellitus
completed lab test needed for complete reporting. A1c level <9.0% for ‘quality’ outcome.
#2. Low Density Lipoprotein Cholesterol (LDL-C) Control in Diabetes Mellitus
completed lab test needed for complete reporting. LDL-C level <100 for ‘quality’ outcome
#3. High Blood Pressure Control in Diabetes Mellitus
Can test & report @ 1st encounter but ‘quality’ requires b/p less than 140/80 mmHg
#117. Dilated Eye Exam in Diabetic Patient
usually requires consultation w/ report to complete this quality mesure.
#119. Urine Screening for Microalbumin or Medical Attention for Nephropathy in Diabetic
Patients
usually requires lab test to report successfully.
#163. Foot Exam
requires either more complete exam (possibly w/o higher CPT), or referral and report
Reporting Measure Groups
• Claims Based
– 80% Sample of Eligible Patients
• 30 minimum Patients for year
• 15 minimum Patients after 7/1/09 (only pays 1%
incentive)
or
– 30 Consecutive Eligible Patients
• Registry Based
– 30 Consecutive Eligible Patients
Considerations
• In 2010 – your data will be basis for public
performance reporting.
– TIP - Avoid reporting noncompliant behavior (a new
admitted diabetic – no eye exam, no foot exam,
missing labs?).
• Key Strategy Point – your sample
population is based on billed ICD-9 codes.
If you don’t list 250.xx on bill, they wouldn’t
count for diabetic measures
Conisderations – cont.
• Cost benefit ratio for 80% sample –
• Potential Revenue
– Medicare Charges(300 vsts./mnth x $80/vst) = $24K/month
– PQRI Bonus $24K*12mnth*2% = $5,760
» Same $ effect as doing additional 1.8 visits/week
– @ 50% overhead = $2,880 MD income
• Added Costs
– Clinician Time for review, documentation, coding
» Added form??
– Medical Records – additional transcription and/or coding
– Billing – additional codes on bills –
• ~33% error rate in 2007 submissions
Considerations – cont.
• 30 sequential patient sample
– Only works for Diabetes Measures Group in
LTC encounters
– Ordering/reporting cycle for eye & foot exams;
only established patients reflect ‘quality care’
• Incorporation of foot exam in 99307-9 visit would
not enhance ‘nature of presenting problem’
– Does your patient population qualify?
• 30 diabetics < 76 years age
– < 10% of typical NF census meets these criteria
Recommended Strategy
• If you have 30+ sample of eligible
diabetics – use measures group
– Identify active, and newly admitted elegibles
– Order any missing tests
– Queue sample for sequential visits (can
intersperse ineligibles w/o affecting PQRI
– Use billing worksheet to select HCPCS codes
– Coordinate w/ billing dept. or use registry
• NCMedSoc has $0 deal w/ docsite registry for
members
Alternate Strategies
• Don’t have 30 eligible Diabetics?
– Don’t participate
• Complexity of reporting multiple individual
measures hard to justify (caveat – may be
mandatory in 2011!)
• Higher risk for failure – too many variables
• Some measures not = best care in LTC setting
– Lobby AGS & AMDA for ‘chronic care’
measures group.
• Requires new individual measures w/ identical
denominator for measure
Claims Based Strategy
• Pick 3 Measures that you can successfully
report on 1st visit:
– One measure must be reported 15 times or
more (minimum # goes into effect 2010)
– Pick 1x/year measures
– Pick process measures (ones you control like ordering antiplatelet therapy for CAD) that
do no harm
– Develop a process, and templates for notes
Recommended Measures for
Claims Based Submission
•
#6 -Coronary Artery Disease (CAD):
Oral Antiplatelet Therapy Prescribed
for Patients with CAD
• #47 – Advanced Care Planning
• #110 – Influenza Immunization
Template Example
• [] Quality Measures
– 4011F – oral antiplatelet therapy ordered for
CAD
– 1124F – patient unable to participate in Adv.
Care Planning; no family member or POA is
available
– G8482 - orders for seasonal flu shot is
present in patient record
PQRI Preliminary Steps
• To access PQRI Data (not payments), providers
have to register w/ CMS for an online account.
This requires:
– Register in PECOS – providers whose last CMS form 855
submission was 2006 or earlier may not be in PECOS and will have to
reregister.
– Register in IACS – this is portal for PQRI reports.
Requires
PECOS eligibility prior to registration.
These processes will test your patience and leave you
questioning the wisdom of a single payor system.