Reporting Periods in 2010 1. Full Year (January 1, 2010 December 31, 2010) eligible professionals (EP) whose PQRI quality measure information is successfully submitted (via claims, measures group, or registry) and satisfies the criteria for successful reporting may earn an incentive payment equal to 2% of their total allowed Part B allowed charges furnished during the entire year. 2. Half Year (July 1, 2010 December 31, 2010) - eligible professionals whose PQRI quality measure information is successfully submitted (via claims, measures group, or registry) and satisfies the criteria for successful reporting may earn an incentive payment equal to 2% of their total allowed Part B allowed charges furnished only during the reporting period, July December 2010. Reporting Options in 2010 To participate in the 2010 PQRI, individual EPs may choose to report information on individual PQRI quality measures or measures groups: (1) to CMS on their Medicare Part B claims, (2) to a qualified PQRI registry, or (3) to CMS via a qualified electronic health record (EHR) product. Individual EPs who meet the criteria for satisfactory submission of PQRI quality measures data via one of the reporting mechanisms above for services furnished during a 2010 PQRI reporting period will qualify to earn a PQRI incentive payment equal to 2.0% of their total estimated Medicare Part B Physician Fee Schedule (PFS) allowed charges for covered professional services furnished during that same reporting period. Beginning with the 2010 PQRI, a group practice may also potentially qualify to earn PQRI incentive payment equal to 2% of the group practice's total estimated Medicare Part B PFS allowed charges for covered professional services furnished during a 2010 PQRI reporting period based on the group practice meeting the criteria for satisfactory reporting specified by CMS. Please note, EPs may choose to pursue more than one 2010 PQRI reporting option. However, an EP who satisfactorily reports under more than one reporting option will earn a maximum of one incentive payment equal to 2.0% of their total estimated allowed charges for Medicare Part B PFS covered professional services furnished during the longest reporting period for which he or she satisfied reporting requirements 1. Claims-Based Reporting: The original PQRI reporting method when a provider reports up to three applicable individual quality measures at or above 80% of the time for the entire calendar year. Each PQRI measure consists of two major components: 1) A denominator that describes the eligible cases for a measure (the eligible patient population associated with a measure s numerator) 2) A numerator that describes the clinical action required by the measure for reporting and performance
Each measure s specification includes a reporting frequency requirement for each denominator eligible patient seen during the reporting period. The reporting frequency is described in the instructions and may be stated as: Report at least once for the specified timeframe Report once for each procedure performed, using date of service Report once for each acute care episode Report each time the patient is seen by an eligible professional A measure s performance timeframe is defined in the measure s description and is distinct from the reporting frequency requirement. The performance timeframe, unique to each measure, delineates the timeframe in which the clinical action described in the numerator may be accomplished. Performance timeframes vary for each measure. Performance timeframes for measures tied to a specific clinical process may be stated as, once within a given reporting period, or most recent. This means that: The clinical action in the numerator needs to be performed only once during a given reporting period for each patient seen during the reporting period. QDC(s) need to be reported only one time for each patient by each eligible professional caring for the patient who has chosen to report that measure during the reporting period. If the measure calls for a clinical test result, then the most recent test result only needs to be obtained, assessed, and reported one time per reporting period. A test does not need to have been performed within the reporting period, nor does it need to have been performed by the same eligible professional. PQRI Quality-Data Codes (QDCs) are HCPCS codes comprised of specified CPT Category II codes and/or G-codes that describe the clinical action required by a measure. Clinical actions can apply to more than one condition, and therefore can also apply to more than one measure. The following principles apply to the reporting of QDCs for PQRI measures: The CPT Category II code(s) and/or G-code(s), which supplies the numerator, must be reported on the same claim form as the payment codes, usually ICD-9- CM and CPT Category I codes, which supply the denominator. QDCs must be submitted with a line item charge of zero dollars ($0.00) at the time the associated covered service is performed. The submitted charge field cannot be blank. The line item charge should be $0.00. If a system does not allow a $0.00 line item charge, use a small amount such as $0.01. Entire claims with a zero charge will be rejected. (Total charge for the claim cannot be $0.00.) Quality-data code line items will be denied for payment, but are then passed through the claims processing system for PQRI analysis. Eligible professionals will receive a Remittance Advice (N365) as confirmation that the QDC(s) passed into the National Claims History file. Multiple eligible professionals QDCs can be reported on the same claim using their individual NPI. Some measures require the submission of more than one QDC in order to properly report the measure. Eligible professionals may submit multiple codes for more than one measure on a single claim. Multiple CPT Category II and/or G-codes for multiple measures that are applicable to a patient visit can be reported on the same claim, as long as the corresponding denominator codes are also line items on that claim. The individual NPI of the participating eligible professional(s) must be properly used on the claim. Claims may not be resubmitted simply to add QDC(s).
2. Measures Groups Reporting: CMS created measures groups subsets of PQRI measures that have in common a focus on a particular clinical condition or aspect of care that allow providers to report on one group of measures, however providers must still report the applicable CPT II or G-code quality data codes for each of the measures in the measures group that are applicable to the patient. The 2010 measure groups are: Diabetes Mellitus, Chronic Kidney Disease (CKD), Preventive Care, Coronary Artery Bypass Graft (CABG), Rheumatoid Arthritis, Perioperative Care, Back Pain, Hepatitis C, Heart Failure, Coronary Artery Disease (CAD), Ischemic Vascular Disease (IVD), HIV/AIDS, and Community-Acquired Pneumonia (CAP). The measures groups most applicable to nephrology practice are composed of the following PQRI measures: Diabetes Mellitus: Measure Number 1 Hemoglobin A1c Poor Control in Type 1 or 2 Diabetes Mellitus Measure Number 2 Low Density Lipoprotein Control in type 1 or 2 Diabetes Mellitus Measure Number 3 High Blood Pressure Control in Type 1 or 2 Diabetes Mellitus Measure Number 117 Dilated Eye Exam in Diabetic Patient Measure Number 119 Urine Screening for Microalbumin or Medical Attention for Nephropathy in Diabetic Patients Measure 163 Diabetes Mellitus: Foot Exam Chronic Kidney Disease (CKD): Measure Number 121 CKD: Laboratory Testing (Calcium, Phosphorus, Intact Parathyroid Hormone (ipth) and Lipid Profile) Measure Number 122 CKD: Blood Pressure Management Measure Number 123 CKD: Plan of Care: Elevated Hemoglobin for Patients Receiving Erythropoiesis-Stimulating Agents (ESA) Measure Number 153 CKD: Referral for Arteriovenous (AV) Fistula Measure Number 135 CKD: Influenza Immunization These measure groups can be reported by one of the following patient sample methods: 30 Patient Sample Method 30 unique patients meeting patient sample criteria for the measures group. 80% Patient Sample Method All patients meeting patient sample criteria for the measures group during the entire reporting period (January 1 through December 31, 2010 OR July 1 through December 31, 2010). For the 12-month reporting period, a minimum of 15 patients must meet the measures group patient sample criteria to report satisfactorily. For the six-month reporting period, a minimum of 8 patients must meet the measures group patient sample criteria to report satisfactorily. The measures group-specific G-codes most applicable to nephrology are: G8485 for Diabetes Mellitus G8487 for Chronic Kidney Disease For example, patient X presents for an office visit on January 11, 2010 with Dr. Smith with a diagnosis of CKD. Dr. Smith selects the CKD measures group as a PQRI reporting option. Dr. Smith reviews specifications for the four measures in the CKD measures group to identify measures applicable to patient X. Dr. Smith submits appropriate CPT II codes based on the measures identified as well as HCPCS code G8487 on patient X s claim form for that January 11, 2010 visit. Dr. Smith then reports 30 unique patients meeting the denominator criteria starting with patient X OR Dr. Smith reports on at least 80 percent of patients during the reporting period meeting the denominator criteria for applicable CKD measures.
CKD Clinical Example: Stage 5 CKD patient, not receiving renal replacement therapy (RRT), office visit: known hypertensive with documented plan of care for hypertension (G8477, 0513F); urinalysis indicates proteinuria, lab tests ordered on last visit and results documented in the chart (3287F); Hgb = 14 and patient is receiving ESA and has plan of care documented for elevated hemoglobin level (3279F, 0514F, 4171F); received flu vaccination at previous visit (4037F); and was referred to vascular surgeon for the placement of AV fistula three months ago (4051F) Dx 1: 585.5; Dx 2: 401.0; Dx 3: 791.0 Measure # Date of CPT/ Diagnosis Modifier Service HCPCS Pointer Charges NPI 01/11/10 99213 1 $50.00 123456789 01/11/10 G8487 1 $0.00 123456789 121 01/11/10 3278G 1 $0.00 123456789 122 01/11/10 G8477 1 $0.00 123456789 122 01/11/10 0513F 1 $0.00 123456789 123 01/11/10 3279F 1 $0.00 123456789 123 01/11/10 0514F 1 $0.00 123456789 123 01/11/10 4171F 1 $0.00 123456789 135 01/11/10 4037F 1 $0.00 123456789 153 01/11/10 4051F 1 $0.00 123456789 3. Registry Reporting: This reporting option requires providers to select a registry which has been approved by CMS as a qualified registry for data collection and once or twice per year data submission. This method is expected to become the preferred method for many providers since they can review the data and add key clinical information regarding the patient at anytime. Additionally, providers DO NOT need to select CPTII codes for registry reporting since the registry performs the measure calculations and performance data is submitted separately from the billing process. There is a shift underway, moving away from claims-based reporting to registry-based reporting and pending the completion of testing EHR-based reporting. Four of the 13 measures groups and 46 of the 175 individual measures may only be reported through a CMS qualified PQRI registry. The registry-only measures most applicable to nephrology practice are composed of the following PQRI individual measures: 81-Plan of Care for Inadequate HD in ESRD Patients, 82-Plan of Care for Inadequate PD in ESRD Patients and 174-Plan of Care for Inadequate HD Pediatric ESRD. 4. Group Practice Reporting Option: New option for 2010. To participate in the 2010 PQRI GPRO, a group practice must comply with certain requirements, submit a self-nomination letter to CMS, and be selected to participate in the 2010 PQRI GPRO. A group practice under the 2010 PQRI GPRO consists of a physician group practice, as defined by a single TIN, with at least 200 or more individual EPs (as identified by Individual NPIs) who have reassigned their billing rights to the TIN. Group practices participating in the Physician Group Practice (PGP) and Medicare Care Management Performance (MCMP) demonstration in 2010 will not be allowed to participate in GPRO for the 2010 PQRI. To participate in the 2010 PQRI GPRO, a group practice must submit a self-nomination letter to CMS and be selected to participate in the 2010 PQRI GPRO. Once a group practice (TIN) is selected to participate in the GPRO, this is the only method of PQRI reporting available to the group and all individual NPIs who bill Medicare
under the group s TIN for 2010. Each group practice selected to participate in the 2010 PQRI GPRO will be provided a pre-populated data collection tool with an assigned sample of patients and those patients demographic and utilization information. The group practice will then be required to populate the remaining data fields necessary for capturing quality measure information on each of the consecutively assigned Medicare beneficiaries with respect to services furnished during the 2010 PQRI reporting period (January 1, through December 31, 2010). The selected group practices will be provided access to the pre-populated tool no later than the first quarter of 2011, which will be completed by the group practice and returned to CMS.