The Centers for Medicare & Medicaid Services (CMS) has continued the Physician Quality Reporting System (PQRS) into 2012 as required under the Medicare Improvements for Patients and Providers Act of 2008. The Affordable Care Act authorized incentive payments for eligible professionals who successfully participate in the program through 2014. The incentive payment for the 2012 reporting year is 0.5 percent of the total allowed charges for Medicare Part B professional services covered under the physician fee schedule and furnished during the reporting period. For reporting years 2013 and 2014, eligible professionals can earn an incentive payment of 0.5 percent of their total estimated allowed charges for Medicare Part B physician fee schedule covered professional services furnished during the respective reporting periods. Beginning in 2015, eligible professionals who fail to satisfactorily report PQRS measures will be subject to a payment adjustment or penalty. Table 1, summarizes the payments during these years.
What are some of the differences between the requirements in the 2011 PQRS and the 2012 PQRS?
In the Medicare physician fee schedule final rule for calendar year (CY) 2012, released on November 1, 2011, CMS finalized several changes to the PQRS for 2012. Major program changes are highlighted in Table 2, page 6.
It is important to note that 2012 PQRS includes 210 individual quality measures and 22 measures that are part of a 2012 measures group. For a copy of the 2012 PQRS measure list, visit here and click on “measures list.” Whereas 2011 PQRS quality measures may be continued in the 2012 PQRS, measures specifications may have been updated for the new program year. Surgeons who are not currently reporting in the 2011 PQRS should review the 2012 PQRS Measure Specifications Manualfor updates and changes.
How do I use the measure specifications manual?
The first step for implementing PQRS in your office is to use the 2012 PQRS Measure Specifications Manual to identify measures applicable for professional services that your practice routinely provides. Next, select those measures that make sense based on prevalence and volume in your practice, as well as your individual or practice performance analysis and improvement priorities. The 2012 PQRS Measure Specifications Manual can be found at this site.
This article outlines the process of claims-based reporting for PQRS 2012—in this case, perioperative measure #21: Perioperative Care: Selection of Prophylactic Antibiotic—First or Second Generation Cephalosporin.
What is the description of the measure?
The specifications describe measure #21 as “Percentage of surgical patients aged 18 years and older undergoing procedures with the indications for a first or second generation cephalosporin prophylactic antibiotic, who had an order for cefazolin or cefuroxime for antimicrobial prophylaxis.” This narrative gives a high-level description of measure #21.
What are the instructions?
The instructions explain when the measure should be reported and who should report it. According to the instructions, measure #21 should be reported “each time a procedure is performed during the reporting period for patients who undergo surgical procedures with the indications for a first or second generation cephalosporin prophylactic antibiotic.” The instructions further state that “there is no diagnosis associated with this measure.” The instructions additionally state that “Clinicians who perform the listed surgical procedures as specified in the denominator coding will submit this measure,” clearly indicating who should report the measure.
What is the “frequency?”
The frequency refers to how often the measure should be reported. Measure #21 should be reported each time an applicable procedure is performed during the reporting period.
How do I report measure #21 via claims?
The measure specifications for measure #21 indicate that it is a claims and registry measure, meaning it can be reported using either the claims-based or the registry-based method. This article looks at the claims-based method only. The Current Procedural Terminology (CPT)* codes and patient demographics identify the patients who are included in measure #21, otherwise known as the denominator. Beginning on page 61 of the 2012 PQRS Measure Specifications Manual, there is a listing of all surgical procedures and CPT codes that qualify patients as eligible to meet this measure’s inclusion requirements (see Table 3). It is important to review the CPT codes associated with each measure reported. Also, please note that the included procedure codes may change from year to year, so review the 2012 measure specifications before beginning to report for this year.
I’ve identified a patient in the denominator for measure #21; now what?
CPT II codes, or quality data codes (QDCs), are used to report the clinical action required by the measure on the claims form. For measure #21, there are three choices: 4041F, 4041F with 1P, and 4041F with 8P. 4041F indicates documentation of order for cefazolin or cefuroxime for antimicrobial prophylaxis (written order, verbal order, or standing order/protocol); 4041F with 1P modifier indicates order for first or second generation cephalosporin not ordered for medical reasons; and 4041F with 8P modifier indicates order for first or second generation cephalosporin not ordered, reason not specified. Please note that both the CPT code and the appropriate CPT II code should be submitted on the same claim form.
Can you provide a step-by-step overview of the process for submitting a claim form?
CPT II codes can be reported on claim form CMS 1500 or via electronic form ASC X12N 837. The Figure on page 9 is an example of the CMS 1500 claim form.
Based on Figure 1, the steps for reporting via claims include the following:
Step 1: Look in the measure specifications for measure #21 to see if this procedure, 44120, is listed in the table of surgical procedures for which there are indications for a first or second generation cephalosporin prophylactic antibiotic. If so, continue to step 2.
Step 2: On the CMS 1500 claim form, the CPT procedure code 44120 is listed on line 1.
Step 3: On line 2, the CPT II code 4041F with 1P is listed, which indicates the order for first or second generation cephalosporin not ordered for medical reasons. Note that the CPT II code may be one of three options, as discussed earlier in this article.
Step 4: Lines 3 through 6 are CPT II codes that correspond to other PQRS measures (#20, #22, and #23). Measures #20, #22, and #23 are often reported by eligible professionals when measure #21 is reported because these four measures are perioperative care measures. CPT procedure code 44120 corresponds with these perioperative measures as well, so the CPT II codes are listed on the same claim form.
Step 5: Be sure billing software and the clearinghouse can correctly submit PQRS CPT II codes or QDCs.
Step 6: Regularly review the remittance advice notice from the carrier to ensure the denial remark code N365 is listed for each QDC submitted. This indicates that claims have made it to the CMS national claims history file.
Surgical practices that follow these steps should be able to successfully report via claims in PQRS 2012 to receive incentive payments. There are various ways to report for PQRS, and this article has only covered the claims-based method for individual measures. Please refer to the correct measure specifications manual if you choose another method. Table 4 is a matrix that lists all six options for reporting in PQRI 2012.
For more background information regarding the PQRS program, go to http://www.cms.hhs.gov/pqrs/ and access the resources posted at http://www.facs.org/ahp/pqrs/index.html. If you have any further questions regarding PQRS, contact Sana Gokak at firstname.lastname@example.org.