Home Analysis New pay-for-reporting program sets its sights on individual physicians

New pay-for-reporting program sets its sights on individual physicians

July 2007

Published in the July 2007 issue of Today’s Hospitalist.

This month marks the debut of a new physician pay-for-reporting program that could mean a little money, perhaps a lot of hassle, and a new era of individual accountability for many physicians, including hospitalists.

The Centers for Medicare and Medicaid Services (CMS) launched its Physician Quality Reporting Initiative (PQRI) on July 1, inviting physicians to individually report on quality measures through the end of this year. Reporting on measures is the key to being eligible for a bonus.

What do hospitalists stand to gain from voluntary reporting? According to Patrick Torcson, MD, who chairs the performance and standards task force for the Society of Hospital Medicine (SHM), hospitalists who participate this year could earn a bonus of about $800 for their efforts.

"For many hospitalists, the PQRI reporting burden may be more onerous than the financial benefit they’ll get out of it," Dr. Torcson said at a session on pay for performance at SHM’s Annual Meeting.

"But we are moving away from getting paid based on volume to a world where we get paid based on results. The real benefit for physicians is the opportunity to develop the skill set for performance measurement and reporting."

A new iteration
The CMS actually launched its first physician reporting program last year with a limited set of measures. Only an estimated 10,000 physicians participated in that program, Dr. Torcson said. PQRI, however, includes several dozen more measures that apply to many more specialties. Among the program’s 74 measures, 11 have reporting specifications that apply to hospitalists. (See "PQRI: a look at what hospitalists can report," below.)

Physicians who report quality data will receive a lump-sum bonus in 2008 of 1.5% of their total Medicare allowed charges. (A bonus cap “really a minimum bonus “is in effect for physician specialties, such as radiation oncology, that can report on fewer than three measures, but that cap shouldn’t apply to hospitalists.) Physicians will also receive a confidential feedback report on their performance from the CMS.

What to report
To qualify for the bonus, physicians must report on at least three measures that pertain to them. Further, they must report on those measures for at least 80% of the patients they treat during the six-month period for whom the measures apply.

In a conference call that the CMS held last month, Susan Nezda, MD, MBA, a CMS official who is leading PQRI outreach efforts, said that hospitalists may want to report on more measures.

"Pick four or five," she said, "so if logistically, things don’t work out on one of those because you don’t report it frequently, you’ll still be eligible for the bonus."

She also urged physicians to start participating now. "Even if you start in August," she explained, "when we do the analysis, we will be looking at your claims from July." Waiting until later this year to report on measures, she noted, will limit your ability to reach the 80% mark.

The fact that more than one physician “such as an ED doctor or even another hospitalist in your group “may end up reporting on the same measure for the same patient during the same hospital stay is fine from CMS’ perspective, Dr. Nezda said.

According to Dr. Torcson, one useful strategy to lighten a group’s reporting burden may be to limit measure reporting to the admission or discharge. And once a physician documents performing a particular measure, such as asking about an advance care plan, other physicians should know not to keep asking patients about that measure again.

How to report
Physicians don’t have to register for PQRI, but they do need to use their individual national provider identification number.

All quality data reporting is claims-based and uses either CPT II codes, a new type of CPT coding system developed by the AMA, or G codes. Claims from participating physicians will need to include these codes or modifiers in addition to the ICD-9 and E/M codes used to bill for medical services.

Dr. Torcson gave this example: You admit a 65-year-old patient for stroke. You consider tPA and order DVT prophylaxis, interventions that are PQRI measures.

Your claim should list the ICD-9 code 434.00 for stroke and an E/M code, such as 99223, for the admission. You would also report the following PQRI quality codes: 4077F for tPA consideration and 4070F for DVT prophylaxis.

Noting exclusions
To allow physicians to note situations that should be excluded from a particular PQRI measure, the CMS has come up with the following exclusion codes:

1P: Exclusion due to medical reasons. You would use this modifier to explain why you’re not prescribing an antiplatelet to a cardiac patient with a bleeding disorder.

2P: Exclusion due to patient reasons. Use this modifier for a patient who refuses to discuss an advance care plan.

3P: Exclusion due to system reasons. Dr. Nezda gave this example: Physicians who can report on giving influenza vaccine (which don’t include hospitalists, at this point) would use this modifier if vaccine was not available.

8P: A catch-all modifier. This allows you to note that a required measure was not met and/or was not documented.

"This is a not-documented or wasn’t-done exclusion," Dr. Nezda pointed out. The advantage of reporting it on claims when you don’t perform and/or document a particular measure is that the claim will then still count toward your 80% eligibility threshold.

So what’s stopping physicians from telling coders to enter 8P for every eligible measure? Technically, nothing, Dr. Nezda admitted. "That would make physicians eligible for the bonus," she said, "but it would limit the potential for improving performance."

Logistical hassles
Down the road, said Dr. Torcson, who also participated in the CMS conference call, physicians may see some kind of integration between what they report as individuals and what hospitals have to report for their medical staff. He admitted that there will be redundant reporting.

For now, he added, it remains to be seen how much of a reporting burden PQRI will present for hospitalists.

It also remains to be seen whether billing personnel will have problems using CPT II and G codes. According to Dr. Torcson, software vendors are now scrambling to retrofit billing systems. His own facility “St. Tammany Parish Hospital in Covington, La. “has created a homegrown system to accommodate the hospitalists’ performance codes.

And there are other unknowns, Dr. Torcson pointed out, such as whether the program will expand next year and how much political momentum there is to turn pay for reporting into pay for performance for physicians.

Phyllis Maguire is Executive Editor of Today’s Hospitalist.

Want more information?

At press time, the CMS announced that a PQRI toolkit would be available online with frequently asked questions and worksheets for individual quality measures.