Frequently Asked Questions: General Topics
Q: What is the Physician Quality Reporting Initiative (PQRI)?
A: The PQRI, an expansion of the Physician Voluntary Reporting Program, is the first volun-tary, national program linking reporting of performance data to physician payment. Clinicians meeting the established reporting criteria will be eligible for a bonus payment of up to 1.5 per-cent of allowed charges on all Medicare claims on services performed between July 1, 2007 and December 31, 2007.
Q: What is a performance measure versus a guideline?
A: Performance measures are developed using established guidelines, which are aids to appropriate care delivery. Measures abstract specific elements of care from the guideline and assign attribution to a physician, multiple physicians or a facility. In addition, measures concretely define which patients are to be included and excluded and allow for comparison between providers.
Q: Do I have to register to participate in the PQRI?
A: No, registration is not required for participation in the PQRI. All Medicare-enrolled eligible professionals--as defined by the Tax Relief and Healthcare Act (TRHCA) of 2006--may partici-pate. To participate in the program, simply begin reporting data on July 1, 2007 and continue reporting through December 31, 2007.
Q: What performance measures are included in the PQRI?
A: There are 74 measures that can be reporting for the 2007 PQRI. PQRI participants should select at least three performance measures applicable to the largest portion of their Medicare practice. If less than three measures are relevant, participants should just report on the one or two applicable measures. A list of the 74 available measures can be found on the ACS and CMS Web sites.
Q: Is there any harm in reporting 4 measures in case I’m concerned that reporting on my top three won’t meet the 80% threshold?
A: There is absolutely no harm in reporting on more than three measures; there will, of course, be a slightly increased burden. However, it’s a personal choice for you to make based on your individual practice. To calculate your bonus payment, the three measures with the highest reporting rates will be used.
Q: Should I be concerned about the payment cap included in the PQRI?
A: To receive the full 1.5 percent bonus payment (and avoid falling under the payment cap), PQRI participants should report of the three or four performance measures that cover the most Medicare patients in their practice. The cap on payments has been created to limit the bonus for physicians who report relatively little quality data. However, due to the cap formula, exactly what this cap will be cannot be determined until all of the 2007 reporting has been completed.
Q: Which measures should I report on?
A: When choosing performance measures, participants should look at their Medicare billing for the previous year and identify the most frequently billed procedures. Once those procedures are identified, participants should look to see which measures apply to their most frequently billed procedures. An excel spreadsheet is available on the ACS Website to help practices identify which measures apply to which procedures.
Q: Are there measures specific to surgery?
In anticipation of the PQRI, the American College of Surgeons (ACS), in collaboration with numerous other specialty societies, developed a set of six physician-level performance measures, known as the Perioperative Care Measure Set. The measure topics include timing of antibiotic prophylaxis, selection of prophylactic antibiotics, discontinuation of prophylactic antibiotics, and venous thromboembolism prophylaxis. All measures have a distinct list of relevant procedures for which the measure applies.
In addition to the perioperative care measures, there are measures related to urinary incontinence, osteoporosis, stroke, gastroesophageal reflux disease, oncology and ophthalmology that may apply to your practice.
Q. If I perform multiple procedures on the same day that are eligible for reporting of performance measures, do I need to report the quality codes (CPT II or g-codes) for each procedure or just once?
A. If the procedures are billed on the same claim form and quality codes are relevant to more than one procedure performed on the same day of service, you only need to report the quality code once. The code will be linked to all relevant procedures on the billing form.
Q: How were these measures selected for the PQRI?
A: The measures included in the 2007 PQRI were developed by physicians, many in collabora-tion with the AMA Physician Consortium for Performance Improvement (PCPI). The measures were also vetted through the AQA (formerly the Ambulatory Care Quality Alliance) and/or the National Quality Forum (NQF), both of which are multi-stakeholder organizations.
Q: Do the quality reporting measures get reported on the assistant surgeon's bill as well as the primary surgeon's bill?
A: The PQRI reporting works exactly the same as the billing, so whoever normally does the billing (be it the primary surgeon or both) will also do the reporting.
Q: How will the quality data be submitted to CMS?
A: Measures will be reported using administrative data to capture clinical information. It will be reported on the same claim form as the procedure code(s), generally using Current Procedural Terminology (CPT) Category II codes, which can be reported on claim form CMS 1500 or electronic transaction ASC X12N 837. ACS has developed many work flowsheets to help practices with this process that are available on its Web site.
Q: How does the payment work?
A: Participants reporting on their selected measures for at least 80 percent of relevant procedures will be eligible for the full 1.5 percent bonus. The bonus will be calculated using all allowed charges for services performed under the Medicare Physician Fee Schedule in the last six months of 2007. Quality codes will be routed through the CMS payment system and analyzed for bonus payment. Then, a single bonus payment will be made in mid-2008 to the holder of the taxpayer identification number.
Q: If I work in a multi-specialty practice or in a practice with many doctors in the same specialty, how does the 80 percent threshold work?
A: You will be evaluated as an individual, but your payment will go to the tax ID number. For example, if you have a practice of 50 physicians and 30 decide to participate in the PQRI, the bonus payment for those 30 physicians will be made to the Tax ID number. We encourage practices to identify a plan for distribution of the payment.
Q: Will my performance data be publicly reported?
A: No, for 2007, CMS has stated that the data will not be reported publicly.
Q: Will I get to see my quality score?
A: Yes, around the same time you receive your bonus payment, you will receive a report from CMS on the quality data you submitted. At a minimum, the report will include the data used to calculate your bonus payment.
Q: What factors should I consider before determining whether to participate in 2007?
A: Some of the issues you might want to consider include the number of Medicare patients in your patient mix, the proportion of your Medicare patients for whom the selected performance measures are applicable, and the amount of extra administrative costs for your individual practice. In addition, you will want to consider the opportunity for your practice to gain experience reporting performance measures while the program is voluntary and is not being publicly reported.
Revised July 10, 2007
Frequently Asked Questions (FAQS)
PQRI
