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Emergency Medicine PQRI (Physician Quality Reporting Initiative) Open Door Forum Hosts CMS, ACEP, & Emergency Medicine PQRI (Physician Quality Reporting Initiative) Open Door Forum Hosts CMS, ACEP, & CEP America 1

Disclaimers This presentation was current at the time it was published or uploaded onto Disclaimers This presentation was current at the time it was published or uploaded onto the web. Medicare policy changes frequently so links to the source documents have been provided within the document for your reference. This presentation was prepared as a tool to assist providers and is not intended to grant rights or impose obligations. Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services. The Centers for Medicare & Medicaid Services (CMS) employees, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this guide. This publication is a general summary that explains certain aspects of the Medicare Program, but is not a legal document. The official Medicare Program provisions are contained in the relevant laws, regulations, and rulings. CPT only copyright 2008 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable FARSDFARS Restrictions Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. 2

Outline § § § § Introduction Reason PQRI was developed Legislative background How measures Outline § § § § Introduction Reason PQRI was developed Legislative background How measures are created Importance Eligible professionals Differences b/w PQRI and Core Requirements for successful PQRI program Example of successful PQRI program 2009 ED relevant PQRI Measures Coding and submission of PQRI measures Current and future challenges References 3

Presenters § Dennis Beck MD FACEP § Chair ACEP Quality & Performance Committee § Presenters § Dennis Beck MD FACEP § Chair ACEP Quality & Performance Committee § President and CEO, Beacon Medical Services § Richard Newell MD MPH § Member ACEP Quality & Performance Committee § CMS Program Coordinator, CEP America § Mike Granovsky MD FACEP § Member ACEP National Coding and Nomenclature Advisory Committee § President of MRSI (Medical Reimbursement Systems, Inc. ) 4

Value Based Purchasing & PQRI § VBP key mechanism for transforming Medicare from passive Value Based Purchasing & PQRI § VBP key mechanism for transforming Medicare from passive payer to active purchaser § Medicare Physician Fee Schedule (PFS) is based on quantity and resources consumed, NOT quality or value of services § Value = Quality ÷ Cost § Incentives higher quality + § Cost containment = § Enhanced value § VBP Issue Paper available at http: //www. cms. hhs. gov/center/physician. asp 5

Legislative Background § TRHCA – Tax Relief & Health Care Act, 2006 established 2007 Legislative Background § TRHCA – Tax Relief & Health Care Act, 2006 established 2007 PQRI § MMSEA - Medicare, Medicaid, and SCHIP Extension Act of 2007 § MIPPA - Medicare Improvements for Patients and Providers Act Section 131: 2009 PQRI 6

Transition to Value-Based Purchasing VBP 2007 2008 2009 2010 • TRHCA • MMSEA • Transition to Value-Based Purchasing VBP 2007 2008 2009 2010 • TRHCA • MMSEA • MIPPA • 74 measures • 119 measures • 153 measures TBD through rulemaking • Claimsbased only • Claims • 4 Measures Groups • 7 Measures Groups • Registry • EHRtesting • e. Rx 7

How Are PQRI Measures Developed? § Created by respected group using a consensus-based process How Are PQRI Measures Developed? § Created by respected group using a consensus-based process § For example the ED relevant measures were developed by: § AMA-PCPI - American Medical Association-sponsored Physician Consortium on Performance Improvement § NCQA - National Committee for Quality Assurance § ACEP is working on future measures § After creation there is a public comment period § Based on comments measures are molded into their final version § Measures are submitted to be endorsed or adopted by a consensus organization such as the National Quality Forum (NQF) 8

ACEP QI Structure § ACEP Standards Taskforce – 1987 § ACEP Clinical Policies Committee ACEP QI Structure § ACEP Standards Taskforce – 1987 § ACEP Clinical Policies Committee published first guideline on Chest Pain in 1990 § Over 22 clinical guidelines have been developed, from which many of ACEP quality measures are derived § ACEP Quality Improvement and Patient Safety Section (QIPS), est. 1993 § Task Force on Quality & Performance, est. 2004 § Quality and Performance Committee (QPC) created in 2005 9

ACEP Activity: “EM” Measures for PQRI § ACEP has been a Member of the ACEP Activity: “EM” Measures for PQRI § ACEP has been a Member of the AMA Physician Consortium for Performance Improvement since 2000 § ACEP Led Consortium’s Workgroup on Emergency Medicine § ACEP/Emergency Medicine Workgroup, developed EM performance measure set for the clinical areas of: § § Acute Myocardial Infarction (AMI) Pneumonia Chest Pain Syncope Result: Measures Eligible for EP PQRI Reporting in 2007 10

ACEP Activity: “EM” Measures for PQRI § ACEP is also active at National Quality ACEP Activity: “EM” Measures for PQRI § ACEP is also active at National Quality Forum to help refine “EM” measures, and other measures that are eventually endorsed l l l Median Time from ED Arrival to ED Departure for Admitted ED Patients. Median time from ED arrival to time of departure from the emergency department for patients admitted to the facility from ED Median Time from ED Arrival to ED Departure for Discharged ED Patients. Median time from ED arrival to time of departure from emergency department for patients discharged from the ED Admit Decision Time to ED Departure Time for Admitted Patients. Median time from admit decision time to time of departure from the ED for emergency department patients admitted to inpatient status Door to Provider. Time of first contact in the ED to the time when the patient sees the physician (provider) for the first time. Left Without Being Seen. Percent of patients leaving w/o being seen by physician Severe Sepsis and Septic Shock: Management Bundle. Initial steps in management of the patient presenting with infection (severe sepsis or septic shock) l l Confirmation of Endotracheal Tube Placement. Any time an endotracheal tube is placed into an airway in the Emergency Department or an endotraceal tube is placed by an outside provider and that patient arrives already intubated (EMS or hospital transfer) or when an airway is placed after patients arrives to the ED there should be some method attempted to confirm ETT placement Pregnancy Test for Female Abdominal Pain Patients. Percent of women, ages 14– 50 years old, who present to ED with chief complaint of abdominal pain who have a pregnancy test (urine or serum) ordered in ED Anticoagulation for Acute Pulmonary Embolus Patients. Percent of patients newly diagnosed with a pulmonary embolus in the ED or referred to the ED with a new diagnosis of pulmonary embolus who have orders for anticoagulation (heparin or low molecular weight heparin) for pulmonary embolus while in the ED Pediatric Weight in Kilograms. Percent ED patients < 13 years of age with a current weight in kilograms documented in ED record Endorsed by NQF in 2008 11

Why Are PQRI Measures Important? § Surrogate for quality § Financial implications § § Why Are PQRI Measures Important? § Surrogate for quality § Financial implications § § Cost control Incentives Pay-for-performance Framework for other payers § Public accountability 12

Eligible Emergency Professionals § Emergency Physicians (MD/DO) § Nurse Practitioners § Physician Assistants 13 Eligible Emergency Professionals § Emergency Physicians (MD/DO) § Nurse Practitioners § Physician Assistants 13

Core & PQRI Measure Differences § Who is accountable for performance? § Core Measure Core & PQRI Measure Differences § Who is accountable for performance? § Core Measure = Hospital § PQRI = Provider § Who reports performance? § Core Measure = Hospital § PQRI = Billing company or provider § What patients are included in the measures? § Core Measure = All admitted patients regardless of payer § PQRI = Both admitted and discharged Medicare Part B patients 14

Successful PQRI Program Requirements § Organizational priority § Collaboration with billing company § Data Successful PQRI Program Requirements § Organizational priority § Collaboration with billing company § Data collection and reporting 15

Successful PQRI Program Requirements § Dedicated position overseeing program § Provider education § Timely Successful PQRI Program Requirements § Dedicated position overseeing program § Provider education § Timely feedback 16

CEP America’s PQRI Program § Began in 2007 § CMS Program Coordinator position created CEP America’s PQRI Program § Began in 2007 § CMS Program Coordinator position created § Provider Education § Constantly updated web-based education § In person presentations at partnership regional meetings and PA/NP meetings § Development of supplemental practice material for placement in department (see example) 17

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CEP America’s Program § Performance reports § Semi-Annual reports on organizational, regional level, & CEP America’s Program § Performance reports § Semi-Annual reports on organizational, regional level, & site level § Program coordinator discusses quarterly performance with medical directors at site § Timely feedback to providers (see example) § Allows for individual provider quality improvement § Department PI projects designed around PQRI performance 19

Site Feedback Report 20 Site Feedback Report 20

Provider Feedback Report 21 Provider Feedback Report 21

Where To Start www. cms. hhs. gov/pqri 22 Where To Start www. cms. hhs. gov/pqri 22

2009 PQRI Measures § There are 153 PQRI measures § There are 10 PQRI 2009 PQRI Measures § There are 153 PQRI measures § There are 10 PQRI Measures relevant to Emergency Medicine 23

ED Provider Quality Measures 1. Aspirin at Arrival for AMI 2. Electrocardiogram Non-Traumatic Chest ED Provider Quality Measures 1. Aspirin at Arrival for AMI 2. Electrocardiogram Non-Traumatic Chest Pain 3. Electrocardiogram Performed for Syncope 4. Vital Signs for Community-Acquired Bacterial Pneumonia 5. Assessment of Oxygen Saturation for Community-Acquired Bacterial Pneumonia 6. Assessment of Mental Status for Community- Acquired Bacterial Pneumonia 7. Empiric Antibiotic for Community-Acquired Bacterial Pneumonia 24

PQRI Additional ED Measures 8. Prevention of Catheter related Infections § Procedure trigger- 36556 PQRI Additional ED Measures 8. Prevention of Catheter related Infections § Procedure trigger- 36556 § Cap, mask, gown, large field, hand washing, full prep 9. Stroke- Patients receiving DVT Prophylaxis § Cross walks to 99291 10. Stroke- Consideration of TPA § Cross walks to 99291 § Retired #29: Beta-Blocker for Acute MI 25

Measure #28: Aspirin in AMI § Measure description: § Percentage of patients, regardless of Measure #28: Aspirin in AMI § Measure description: § Percentage of patients, regardless of age, with an ED diagnosis of AMI who had documentation of receiving aspirin within 24 hours before ED arrival or during ED stay § If not going to provide ASA, document why § Applicable E&M Levels: 99281, 99282, 99283, 99284, 99285, 99291 § Applicable ICD-9 diagnosis codes: 410. 01, 410. 11, 410. 21, 410. 31, 410. 41, 410. 51, 410. 61, 410. 71, 410. 81, 410. 91 26

Measure #31: DVT PPx in Stroke & ICH § Measure Description: § Percentage of Measure #31: DVT PPx in Stroke & ICH § Measure Description: § Percentage of patients aged 18 years and older with a diagnosis of ischemic stroke or intracranial hemorrhage who received DVT prophylaxis by end of hospital day two § Acute ischemic stroke patients recommend prophylactic low-dose subcutaneous heparin or low-molecular-weight heparins § Acute ICH, recommend the initial use of intermittent pneumatic compression § If not going to provide document medical or patient reason why not § Applicable E&M Level: 99291 only § Applicable ICD-9 diagnosis codes: 431, 433. 01, 433. 11, 433. 21, 433. 31, 433. 81, 433. 91, 434. 01, 434. 11, 434. 91 27

Measure #34: t-PA in Ischemic stroke § Measure description: § Percentage of patients aged Measure #34: t-PA in Ischemic stroke § Measure description: § Percentage of patients aged 18 years and older with a diagnosis of ischemic stroke whose time from symptom onset to arrival is less than 3 hours who were considered for t-PA administration § Includes patients to whom t-PA was given or patients for whom reasons for not being a candidate for t-PA therapy are documented § Ensure documentation of reasons why t-PA is not being administered § Applicable E&M Levels: 99291 only § Applicable ICD-9 diagnosis codes: 410. 01, 410. 11, 410. 21, 410. 31, 410. 41, 410. 51, 410. 61, 410. 71, 410. 81, 410. 91 28

Measure #54: EKG in Chest Pain § Measure description: § Percentage of patients aged Measure #54: EKG in Chest Pain § Measure description: § Percentage of patients aged 40 years and older with an emergency department discharge diagnosis of non-traumatic chest pain who had a 12 -lead electrocardiogram (ECG) performed § If not going to obtain an EKG document medical or patient reason for not doing so § Applicable E&M Levels: 99281, 99282, 99283, 99284, 99285, 99291 § Applicable ICD-9 diagnosis codes: 413. 0, 413. 1, 413. 9, 786. 50, 786. 51, 786. 52, 786. 59 29

Measure #55: EKG in Syncope § Measure description: § Percentage of patients aged 60 Measure #55: EKG in Syncope § Measure description: § Percentage of patients aged 60 years and older with an ED diagnosis of syncope who had a 12 -lead ECG performed § If not going to provide obtain an EKG document medical or patient reason for not doing so § Applicable E&M Levels: 99281, 99282, 99283, 99284, 99285, 99291 § Applicable ICD-9 diagnosis code: 780. 2 30

Measure #56: Vital Signs in CAP § Measure description: § Percentage of patients aged Measure #56: Vital Signs in CAP § Measure description: § Percentage of patients aged 18 years and older with a diagnosis of community-acquired bacterial pneumonia with vital signs (temperature, pulse, respiratory rate, and blood pressure) documented and reviewed § Definition of documented and reviewed: § Clinician documentation that vital signs were reviewed § Dictation by the clinician including vital signs § Clinician initials in the chart that vital signs were reviewed, or other indication that vital signs had been reviewed § Applicable E&M Levels: 99281, 99282, 99283, 99284, 99285, 99291 § Applicable ICD-9 diagnosis code: 481, 482. 0, 482. 1, 482. 2, 482. 30, 482. 31, 482. 32, 482. 39, 482. 40, 482. 41, 482. 42, 482. 49, 482. 81, 482. 82, 482. 83, 482. 84, 482. 89, 482. 9, 483. 0, 483. 1, 483. 8, 485, 486, 487. 0 31

Measure #57: Oxygenation in CAP § Measure description: § Percentage of patients aged 18 Measure #57: Oxygenation in CAP § Measure description: § Percentage of patients aged 18 years and older with a diagnosis of community-acquired bacterial pneumonia with oxygen saturation documented and reviewed § Definition of documented and reviewed: § Clinician documentation that oxygen saturation was reviewed § Dictation by the clinician including oxygen saturation § Clinician initials in the chart that oxygen saturation was reviewed or other indication that oxygen saturation had been reviewed § If not going to document and review, document medical, patient, or system reason(s) for not doing so § Applicable E&M Levels: 99281, 99282, 99283, 99284, 99285, 99291 § Applicable ICD-9 diagnosis code: 481, 482. 0, 482. 1, 482. 2, 482. 30, 482. 31, 482. 32, 482. 39, 482. 40, 482. 41, 482. 49, 482. 81, 482. 82, 482. 83, 482. 84, 482. 89, 482. 9, 483. 0, 483. 1, 483. 8, 485, 486, 487. 0 32

Measure #58: Mental Status in CAP § Measure description: § Percentage of patients aged Measure #58: Mental Status in CAP § Measure description: § Percentage of patients aged 18 years and older with a diagnosis of community-acquired bacterial pneumonia with mental status assessed § Definition of mental status assessment: § Medical record may include documentation by clinician that patient’s mental status was noted (e. g. , patient is oriented or disoriented) § Applicable E&M Levels: 99281, 99282, 99283, 99284, 99285, 99291 § Applicable ICD-9 diagnosis code: 481, 482. 0, 482. 1, 482. 2, 482. 30, 482. 31, 482. 32, 482. 39, 482. 40, 482. 41, 482. 42, 482. 49, 482. 81, 482. 82, 482. 83, 482. 84, 482. 89, 482. 9, 483. 0, 483. 1, 483. 8, 485, 486, 487. 0 33

Measure #59: Abx Selection in CAP § Measure description: § Percentage of patients over Measure #59: Abx Selection in CAP § Measure description: § Percentage of patients over 18 years old with a diagnosis of CAP with an appropriate empiric antibiotic prescribed § Definition of appropriate empiric antibiotic § Four drug classes: Fluoroquinolones, Macrolides, Doxycycline, Beta Lactam with Macrolide or Doxycycline § "Prescribed" includes patients who are currently receiving medication(s) that follow the treatment plan recommended at an encounter during the reporting period, even if the prescription for that medication was ordered prior to the encounter § If not going to provide appropriate antibiotic, document medical, patient, or system reason(s) for not doing so § Applicable E&M Levels: 99281, 99282, 99283, 99284, 99285, 99291 § Applicable ICD-9 diagnosis code: 481, 482. 0, 482. 1, 482. 2, 482. 30, 482. 31, 482. 32, 482. 39, 482. 40, 482. 41, 482. 42, 482. 49, 482. 81, 482. 82, 482. 83, 482. 84, 482. 89, 482. 9, 483. 0, 483. 1, 483. 8, 485, 486, 487. 0 34

Measure #76: CVC Insertion § Measure description: § Percentage of patients, regardless of age, Measure #76: CVC Insertion § Measure description: § Percentage of patients, regardless of age, who undergo central venous catheter (CVC) insertion for whom CVC was inserted with all elements of maximal sterile barrier technique § Definition of maximal sterile barrier technique: § Cap AND mask AND sterile gown AND sterile gloves AND a large sterile sheet AND hand hygiene AND 2% chlorhexidine for cutaneous antisepsis) followed § If not going to use maximal sterile barrier technique document the patient reason why not § Acceptable CPT procedure codes: 36555, 36556, 36557, 36558, 36560, 36561, 36563, 36565, 36566, 36568, 36569, 36570, 36571, 36578, 36580, 36581, 36582, 36583, 36584, 36585, 93503 35

Measure Submission Overview § Currently Emergency Medicine relevant PQRI measures are submitted via a Measure Submission Overview § Currently Emergency Medicine relevant PQRI measures are submitted via a claims based mechanism. § Possibly in future via EHR § Reporting period: January 1, 2009 – December 31, 2009 § Satisfactory reporting: § > 3 PQRI measures or 1 -2 measures if <3 measures apply § > 80% of applicable Medicare Part B FFS patient claims for 1 -3 measures 36

PQRI Operational Process § The cohort population for a TIN/NPI is identified. This occurs PQRI Operational Process § The cohort population for a TIN/NPI is identified. This occurs by reviewing the denominator of the measure. § CMS will identify claims with ICD 9 Diagnosis Codes. For example C/W Acute MI § i. e. 410 code family § Then CMS will look for the eligible CPT code for a service provided for this patient. § The dual requirement of 9928 x and ICD 9 code 410. X will trigger the PQRI reporting requirement § CMS then requires the physician report the code for the MI quality measure (if this is one of the measures the EP chooses to report). § Aspirin for Acute MI § 4084 F 37

CMS PQRI Data Flow Critical Step Visit Documented in Encounter Form the Medical Record CMS PQRI Data Flow Critical Step Visit Documented in Encounter Form the Medical Record Coding & Billing N-365 NCH Analysis Contractor Confidential Report National Claims History File Carrier/MAC Incentive Payment 38

Claims-Based Reporting Principles § The CPT Category II code(s) and/or G-code(s), which supply the Claims-Based Reporting Principles § The CPT Category II code(s) and/or G-code(s), which supply the numerator, must be reported: § § on the same claim for the same beneficiary for the same date of service (DOS) for the same EP (NPI within the holder of the tax ID number - NPI/TIN) § All diagnoses reported on the base claim will be included in PQRI analysis. § Claims may NOT be resubmitted simply to add or correct QDCs. § QDCs must be submitted with a line-item charge of zero dollars ($0. 00) at the time the associated covered service is performed. § If a system does not allow a $0. 00 line-item charge, a nominal amount can be substituted ($0. 01). § The submitted charge field cannot be blank. 39

Claims-Based Reporting Process § Entire claims with a zero charge will be rejected § Claims-Based Reporting Process § Entire claims with a zero charge will be rejected § Total charge for the claim cannot be $0. 00 § QDC line items will be denied for payment by the carrier, but are then passed through the claims processing system for PQRI analysis § EPs will receive a Remittance Advice (RA) associated with the claim which contains the PQRI QDC line-item and will include a standard remark code (N 365) § A message that confirms that the QDCs passed into the National Claims History (NCH) file. N 365 reads: “This procedure code is not payable. It is for reporting/information purposes only. ” § The N 365 remark code does NOT indicate whether the QDC is accurate for that claim or for the measure the EP is attempting to report. 40

CMS-1500 Claim Example of an individual NPI reporting on a single CMS-1500 claim. See CMS-1500 Claim Example of an individual NPI reporting on a single CMS-1500 claim. See http: //www. cms. hhs. gov/manuals/downloads/clm 104 c 26. pdf for more information. Qualified PQRI (Dx) listed in Item 21. Up to 8 QDC codes must be submitted with a Dx may be entered electronically. line-item charge of $0. 00. Charge field 24 D. CPT Codes 9928 x cannot be blank. Diabetes Mellitus CAD Identifies claim lineitem DM–PQRI #2 BP<130 mm. Hg–PQRI #3 AND CAD–PQRI #6 BP< 80 mm. Hg–PQRI #3 For group billing, the rendering NPI number of the individual EP who performed the service will be used from each line-item in the PQRI calculations. UI Assessed–PQRI #48 § § § § The patient was seen for an office visit (99213). The provider is reporting several measures related to diabetes, coronary artery disease (CAD), and urinary incontinence: Measure #2 (LDL-C) with QDC 3048 F + diabetes line-item diagnosis (24 E points to DX 250. 00 in Item 21); Measure #3 (BP in Diabetes) with QDCs 3074 F + 3078 F + diabetes line-item diagnosis (24 E points to Dx 250. 00 in Item 21); Measure #6 (CAD) with QDC 4011 F + CAD line-item diagnosis (24 E points to Dx 414. 00 in Item 21); and Measure #48 (Assessment - Urinary Incontinence) with QDC 1090 F. For PQRI, there is no specific diagnosis associated with this measure. Point to the appropriate diagnosis for the encounter. Note: All diagnoses listed in Item 21 will be used for PQRI analysis. Measures that require the reporting of two or more diagnoses on claim will be analyzed as submitted in Item 21. NPI placement: Item 24 J must contain the NPI of the individual provider that rendered the service when a group is billing. This includes putting the individual NPI on the QDC line-items as well. The Tax ID associated with the NPI(s) on this claim is shown in Item 25. Diag pointer field must contain ICD 9 PQRI trigger 41 23

PQRI-Scoring § Scores will be reported as a percentage of compliance § Numerator- the PQRI-Scoring § Scores will be reported as a percentage of compliance § Numerator- the number of patients with a PQRI code/modifier assigned § Denominator-all Medicare patients with the diagnosis of acute MI and the level of services (CPT code) noted in the specification. 42

Meeting The Requirements § QDCs translate clinical actions so they can be captured in Meeting The Requirements § QDCs translate clinical actions so they can be captured in the administrative claims process – they describe whether: § The measure requirement was met – OR – § The measure requirement was not met due to documented allowable performance exclusions (i. e. , using CPT II performance exclusion modifiers – OR – § The measure requirement was not met and the reason is not documented or is not consistent with an accepted performance exclusion 43

PQRI Modifiers § The provider documents appropriate performance of the measure § Report the PQRI Modifiers § The provider documents appropriate performance of the measure § Report the unmodified code: i. e. 4084 F § What if the quality measure was not achieved? § Add a P Modifier: § § 1 P Documentation of Medical reason 2 P Documentation of Patient reason 3 P Documentation of System reason 8 P Reason not otherwise specified in CPT) 44

PQRI Coding Process - ASA for AMI § Aspirin within 24 hours of arrival PQRI Coding Process - ASA for AMI § Aspirin within 24 hours of arrival or during the ED stay § CPT 2 Code: 4084 F Aspirin received within 24 hours before ED arrival or during ED stay § Aspirin not received 24 hours before ED arrival or during ED stay § 1 P: Documentation of medical reasons for not receiving Aspirin § 2 P: Documentation of patient reasons for not receiving Aspirin § 8 P: Aspirin not received, reason not specified 45

PQRI Aspirin Vignette § A 72 year old female presents with an Acute MI. PQRI Aspirin Vignette § A 72 year old female presents with an Acute MI. The physician documents giving Aspirin - Report 4084 F § A 68 year old male presents with an Acute MI. The physician documents not giving ASA due to a Hx of anaphylaxis - Report 4084 F, 1 P (medical reason) § A 26 year old male using Crack presents with an acute MI and refuses Aspirin - Report 4084 F, 2 P (patient reason) § An 82 year old male is brought in by EMS with an acute MI. Aspirin is perhaps given by EMS - Report 4084 F, 8 P (reason not specified) 46

2007 PQRI Experience Report QDC Submission Attempts § 12. 15% Missing NPI § 18. 2007 PQRI Experience Report QDC Submission Attempts § 12. 15% Missing NPI § 18. 89% Incorrect HCPCS code § 13. 93% Incorrect DX code § 7. 24% Both incorrect HCPCS code and incorrect DX code* § 4. 97% All line items were QDCs only 47

PQRI Results: 2007 Claims Data § 631, 110 unique Tax ID/National Provider Identifiers had PQRI Results: 2007 Claims Data § 631, 110 unique Tax ID/National Provider Identifiers had an opportunity to participate § 109, 000 (15. 74%) attempted to participate § Certain specialties were more successful than others- emergency medicine, ophthalmology, and anesthesia 48

PQRI Economic Experience § What does the PQRI bonus mean? § 2007 Total: $36 PQRI Economic Experience § What does the PQRI bonus mean? § 2007 Total: $36 million § Average individual payment = $600 at 1. 5% for 6 months § Average group payment = $4, 700 § Largest group payment = $205, 700 § Opting out vs. Future requirements § 109, 000 reported in 2007 § 56, 700 met reporting requirements 49

Common Errors § Eligible claim without individual NPI § Eligible claim without QDC(s) § Common Errors § Eligible claim without individual NPI § Eligible claim without QDC(s) § Eligible claim submitted as a QDC-only claim (no denominator information on the claim) § Ineligible claim with QDC for measure § Diagnosis is incorrect on claim for measure reported § Surgical procedure is incorrect on claim for measure reported § Age is incorrect for measure reported 50

PQRI- The Feedback Reports § Confidential Feedback Reports today § Hospital data is public PQRI- The Feedback Reports § Confidential Feedback Reports today § Hospital data is public § Reporting of successful participation may occur in the future. 51

2009 Physician Final Rule CMS-1403 -FC Page 655, 664 “We are contemplating a physician 2009 Physician Final Rule CMS-1403 -FC Page 655, 664 “We are contemplating a physician compare website…for the public reporting of quality data” “It is our intent to identify the eligible professionals who satisfactorily submit data on quality measures for the 2009 PQRI on the CMS Web site in 2010” 52

Getting Your Scores § Register in the IACS System § Individual Authorized Access to Getting Your Scores § Register in the IACS System § Individual Authorized Access to CMS Computer Services § First Designate a security officer § Information required § Taxpayer Identification Number (TIN); § Legal Business Name; § Corporate Address; and § Internal Revenue Service (IRS) CP-575 hard copy form. § IACS User Help Desk § 1. 866. 484. 8049 § [email protected] com 53

Getting Your Scores Without IACS 54 Getting Your Scores Without IACS 54

Non IACS Score Reports § CMS has an alternate mechanism for 2008 PQRI feedback Non IACS Score Reports § CMS has an alternate mechanism for 2008 PQRI feedback reports § Beginning on October 19, 2009, individual EPs can call their respective carrier or A/B MAC Provider Contact Center to request 2007 Re-Run and 2008 PQRI feedback reports that will contain data based on their individual NPI. § When requesting feedback reports, EPs will be asked to provide an e-mail address. EPs can then expect to receive the e-mailed feedback report within 30 days of the request 55

Provider Contact List § Carrier Provider Contact Centers can answer questions concerning incentive payment Provider Contact List § Carrier Provider Contact Centers can answer questions concerning incentive payment status, such as: § Was my incentive payment sent? § What is my incentive payment amount? § What does my Remittance Advice(s) mean? § Provider Contact Centers http: //www. cms. hhs. gov/MLNProducts/Downloads/C all. Center. Toll. Num. Directory. zip 56

The Future § Expansion of reporting options: § Claims based § EHR base § The Future § Expansion of reporting options: § Claims based § EHR base § Registry based Movement away from claims based reporting “While we propose to retain the claims based reporting mechanism for 2010, we note that we are considering significantly limiting the claims-based mechanism…after 2010. ” 57

The Future – 2010 Proposed Rule § PQRI Measure #34 Stroke and Stroke Rehabilitation: The Future – 2010 Proposed Rule § PQRI Measure #34 Stroke and Stroke Rehabilitation: Tissue Plasminogen Activator § “Analytically challenging” § Potentially replaced with another measure § Pneumonia Measures group § Measures #56, 57, 58, and 59 § Reportable within the framework of a measures group 58

Resources § Physician Quality Reporting Initiative: § https: //www. cms. hhs. gov/pqri § CMS Resources § Physician Quality Reporting Initiative: § https: //www. cms. hhs. gov/pqri § CMS Quality Initiatives – General Information: § http: //www. cms. hhs. gov/Quality. Initiatives. Gen. Info/ § 12/9/08 Issues Paper: Development of a Plan to Transition to a Medicare Value-Based Purchasing Program for Physician and Other Professional Services § http: //www. cms. hhs. gov/center/physician. asp § Hospital Quality Reporting: § www. hospitalcompare. hhs. gov § Open Door Forums: § http: //www. cms. hhs. gov/Open. Door. Forums/ § National Provider Identifier: § https: //nppes. cms. hhs. gov/NPPES/Welcome. do § Demonstrations: § http: //www. cms. hhs. gov/Demo. Projects. Eval. Rpts/ 59

Resources §American Medical Association – Physician Consortium for Performance Improvement §http: //www. ama-assn. org Resources §American Medical Association – Physician Consortium for Performance Improvement §http: //www. ama-assn. org §National Committee on Quality Assurance §http: //www. ncqa. org/ §National Quality Forum §http: //www. qualityforum. org §Medicare Payment Advisory Commission §http: //www. medpac. gov §National Academies Press – Pathways to Quality Health Care series – performance measurement and improvement §http: //www. nap. edu 60

Resources § American College of Emergency Physicians § www. ACEP. org § Angela Franklin, Resources § American College of Emergency Physicians § www. ACEP. org § Angela Franklin, Esq. § Director of Quality and Health IT § [email protected] org § David Mc. Kenzie, CAE § Reimbursement Director § [email protected] org § CEP America § www. CEP. com § Richard Newell MD MPH § Richard. [email protected] com` 61

Questions? 62 Questions? 62