2007 PHYSICIAN QUALITY REPORTING INITIATIVE (PQRI) by Jeffrey Kaufman, M.D., FACS

PQRI is upon us. Although reporting efforts will ultimately be reimbursed, many have felt that the potential payment available was not worth the effort involved (at least 80% compliance with at least 3 different applicable criteria is eligible for a bonus payment up to a maximum of 1.5% of all Medicare allowable charges for the interval involved capped by a complicated formula related to the volume of reported events). Certainly this is true if reporting takes significant work, thought, energy or overhead. However, if the process can be made streamlined and effortless by automating your reporting, then the financial reward is an attractive addition to your bottom line.

Out of the potential 74 different measures available currently, there are only 5 that really pertain to most urology practices and 3 of those need only be reported once this year to qualify. The fact is that almost every urologist already performs the quality events PQRI is surveying. Therefore, the process does not involve changing practice patterns; it merely requires that you report what you already do. (I will leave aside for the moment any editorial arguments that the PQRI effort will not have any impact on overall quality since it is most likely only going to reward those who already provide quality care; those who do not are not likely to participate and the rewards are insufficient to have any real impact on practice patterns. Thus the program is better characterized as Pay for Reporting than Pay for Performance).

If reporting requires you to search through your records, expend any mental energy considering which code to use and when, or spend any time deciding how to enter the CPT II information, then the financial rewards are insufficient to warrant your participation. However, a little planning up front should allow the process to become routine and automatic and thus cost effective. This shouldn’t be a problem for those with EMR. However, even for paper based offices like ours, we have developed a simplified system that will involve a minimum of effort and allow us to participate with virtually no increase in time, energy or overhead costs. The goal is to simplify reporting and minimize our workload.

Like most urologists, we already perform and document the events in question so participating is nothing more than reporting our compliance. Since the 3 incontinence codes (assessing the presence or absence of urinary incontinence in women over 65 years old, characterizing the type of urinary incontinence and documenting a plan of care for urinary incontinence) need be documented and reported but once per year, we place an easy to identify checklist on the outside of the chart telling us at a glance whether the criteria have been reported this year or not. If not, at check out for all new and return visits for women over 65 years old, our superbill is checked next to the CPT code for the visit to tell our billers to add the CPT II code indicating that we asked about and documented the presence or absence of incontinence (this is done regardless of the actual presenting complaint). The superbill is also starred next to the CPT code for incontinence (urge, stress or other) to indicate that any identified incontinence was characterized and a plan of action documented when incontinence is the reason for which the patient was seen (placing that patient among the denominators in calculating participation in that criteria category). If our billers see a check or star (and many charts have both), they automatically add the appropriate CPT II code to the superbill that day (CPT II codes used for PQRI must accompany the appropriate CPT code for the E&M visit on the same bill to count toward participation. They may not be added on a subsequent bill nor may the bill be re-submitted to add a CPT II code if you forgot to include it originally). Many bills will include all 3 CPT II codes if the visit actually was for a complaint of incontinence. If the patient’s chart indicates that the pertinent CPT II codes have already been submitted once, no further checks or stars are added to the superbill and no further CPT II codes are submitted to CMS on that patient this year.

With regard to the two surgical codes, since we utilize appropriate DVT prevention efforts and prophylactic antibiotics on every surgical patient, our billers are automatically submitting the appropriate CPT II codes along with the charges for all operations (placing the CPT II codes more than once per claim if more than one surgery is billed on that date). This will inevitably involve some over-reporting since the PQRI criteria do not indicate that DVT or antibiotic prophylaxis is necessary on every surgical procedure. However, it takes too much effort for our billers to cross check our surgical codes with the list of those requiring DVT or antibiotic prophylaxis every time they submit a claim. If it is necessary to spend that amount of time and mental energy to limit reporting to only those procedures on the list, the process immediately becomes cumbersome and our overhead costs out weigh the rewards. We feel it is better to over-report than spend too much time thinking about which codes to report on or fail to meet the 80% participation threshold to qualify for reimbursement.

Our system is set up to be as automatic as possible and require the least possible time and thought process. It assumes that the work was done properly and adequately documented. The reality is that, although all reports are subject to retroactive review, CMS simply lacks adequate staff and resources to reasonably review anything more than a mere token of the multiple millions of reported submitted claims this program will generate. They are far more interested in developing participation among physicians than they are with technical compliance at this time. The potential for any chart to be reviewed for PQRI compliance in the near future is between slim and none. Again, the program is designed as nothing more than Pay for Reporting which you either do or don’t. There is little you can do to fail at this unless you refuse to report at least 80% of the events included in the criteria’s denominator.

To further simplify our participation, we have elected to ignore all exclusionary modifiers for the present (1P, 2P, 3P or 8P) since we virtually always have done the work that the PQRI reporting addresses. In the future, these explanations for why the event was not performed even though reported may become more appropriate.

In this simplified fashion, we have entered into the brave new (but ultimately futile) world of Pay for Performance reporting. Many of you have already been participating in similar programs with private payers, often in managed care groups. However, for the rest, the mantra of Performance Based Purchasing has become an article of faith in Washington and various state capitols. We might as well become experienced in the process since it promises to be with us for a very long time to come and future participation is unlikely to remain voluntary. And the bottom line is, if you do it, they will pay.

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