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Renal Physicians
Association
1700 Rockville Pike
Suite 220
Rockville MD 20852
Phone: 301-468-3515
Fax: 301-468-3511
EMail: rpa@renalmd.org

What's New

CMS announces new PQRI reporting criteria effective July 1, 2008
For nephrology practices that have not yet started reporting quality reporting data under Medicare’s Physician Quality Reporting Initiative (PQRI), there is still time to participate in the 2008 program. The Centers for Medicare and Medicaid Services (CMS) recently established new reporting options that will make it easier for nephrology practices to participate in PQRI, though the potential 1.5 percent bonus will only apply to claims submitted between July 1, 2008 and December 31, 2008.

CMS announced new alternative reporting criteria and periods for 2008 PQRI to comply with the Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA), requiring the agency to establish alternative reporting periods and alternative criteria for satisfactorily reporting groups of measures as well as establish alternative criteria for satisfactorily reporting quality measures data through registries.

In addition to the current PQRI requirements, CMS created four measures groups – subsets of PQRI measures that have in common a focus on a particular clinical condition or aspect of care – allowing 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 group that are applicable to the patient. The four measure groups are: Diabetes Mellitus, End Stage Renal Disease (ESRD), Chronic Kidney Disease (CKD), and Preventive Care.

CMS PQRI Fact Sheet

Background

The Centers for Medicare and Medicaid Services’ (CMS) Physician Quality Reporting Initiative (PQRI) will continue in 2008. Beginning January 1, 2008, physicians and other providers who report certain quality measures may be eligible for a 1.5% payment increase, likely to be subject to a cap, to be paid in the second quarter of 2009. To assist nephrologists who may elect to participate in this program, RPA has compiled useful information developed by the RPA, the American Medical Association (AMA), as well as CMS to identify measures relevant to their practice and facilitate the data collection required to successfully report clinical performance data.

As it was in 2007, participation in the program is entirely voluntary. Further, RPA members considering participation in the program should bear in mind that there remain unresolved issues concerning the program, particularly how the potential payment cap, based on the Secretary of Health and Human Services’ discretion, will impact the bonus payments provided for successfully reporting the measures. It is possible that the bonus payment will not cover the expenses associated with participating in the program.

For 2008, RPA has identified nine PQRI measures most applicable to nephrology practices, five specific to ESRD and four specific to CKD care. These measures were developed by the RPA in conjunction with the AMA-convened Physician Consortium for Performance Improvement. A complete list of all 119 quality measures can be found at www.cms.hhs.gov/pqri.

2008 Toolkit Contents

RPA’s PQRI ‘toolkit’ includes:

An RPA ‘Frequently-Asked Questions’ (FAQ) document that provides extensive background on participation in the program, updated for 2008;
A list of ESRD and CKD quality measures that may be most appropriate for use by nephrologists;
A series of worksheets intended for use by nephrology practice staff that will assist in the tracking of the measure information for reporting purposes.

Measure Description – This document contains additional descriptive information regarding the measure and should help users determine if it is a measure on which they would like to report. In particular, the document describes what type of information is required to report on the measure and how frequently reporting is required.
Data Collection Sheet – A step-by-step tool for clinical use and office/billing staff use. It allows the physician or other eligible professional to record the clinical information required for the measure by checking the appropriate box, and the coder to subsequently select the corresponding billing code.

2008 RPA PQRI TOOLKIT MATERIALS

PQRI FAQs

ESRD and CKD Quality Measures

Nephrology Measures Worksheets

2007 PQRI Information

Coding Specifications - Includes a complete list of ICD-9 and CPT codes to identify patients eligible for the measure. A list of the quality codes for each measure is also included. The coding specifications document is to be used in conjunction with the data collection sheet to determine the appropriate code or combination of codes to be reported.

RPA PQRI TOOLKIT MATERIALS

Basic Participation Facts

Individual-level NPIs are Required — The analysis of whether an eligible professional has successfully reported will be performed at the individual eligible professional level using the individual-level National Provider Identifier (NPI), and thus to participate in the program a provider must have an individual NPI.
No need to enroll or register to begin claims-based reporting — Participating eligible professionals whose Medicare patients fit the specifications of the 2008 PQRI quality measures will report the corresponding appropriate CPT Category II codes or G-codes (where CPT Category II codes are not yet available) on their claims.

RPA PQRI TOOLKIT MATERIALS

PQRI Preparation Strategies

Review RPA Toolkit Materials to familiarize yourself with the program. By reviewing the materials provided, nephrology practices may be able to determine the feasibility of participation in the PQRI program. In addition, CMS has developed several educational resources that are available through their PQRI website. One resources in particular may be of most help to RPA members.
1. 2008 Coding for Quality Handbook - A Handbook that delineates coding and reporting principles and provides implementation guidelines for how to successfully report measures using clinical scenarios.
  - Read and discuss the principles, clinical scenarios, and implementation guidelines for each of the measures selected for reporting in PQRI.
  - Develop a process for concurrent data collection so that PQRI codes are correctly identified and entered onto Medicare FFS claims.
  - Review the sample workflow diagram included in the Handbook to plan any changes to workflow so that all PQRI quality data codes may be captured on claims for Medicare services.
Select Measures - While there are nine quality measures specific to ESRD and CKD care, Nephrology practices should review the complete list of measures (available at www.cms.hhs.gov/pqri) to determine which of them may apply to your patient population. For example, if you also manage diabetes or hypertension for your patients then review the measure specific to those conditions and select one or more to report. As mentioned above, the RPA PQRI toolkit contains a list of the ESRD and CKD quality measures that are most appropriate for use by nephrologists.
Define Team Roles - Your billing staff is going to be integral in the successful reporting of these measures. Select one or more individuals on your staff to be responsible for ensuring the rest of the team is knowledgeable about PQRI matters.
Modify Workflows and Billing Systems -In order to successfully report a quality reporting CPT code, you must have laboratory values that typically are captured at the dialysis facility. Your billing staff may need to develop a protocol for obtaining URR and Hematocrit/Hemoglobin values when submitting your MCP claims with quality reporting codes.

As more information on the program becomes available, RPA will share it with our members. Questions on the PQRI program may be directed to Holly Owens, RPA’s Director of Legislative and Regulatory Affairs, at 301-468-3515, or by email at howens@renalmd.org.

RPA PQRI TOOLKIT MATERIALS

RPA Guidance on The Medicare Physicians Quality Reporting Initiative (PQRI)

RPA PQRI TOOLKIT MATERIALS

PQRI Preparation Strategies

RPA Guidance on
The Medicare Physicians Quality Reporting Initiative (PQRI)