Radiology Specific PQRI Frequently Asked Questions
Radiology Specific PQRI FAQs
1) Is the bonus based on professional and technical component billings? What about radiopharmaceuticals?
The statute defines PQRI covered services as those paid under the Medicare Physician Fee Schedule. The PQRI quality measures are meant for physician reporting only and can include technical and professional components of diagnostic services when billed globally. If a physician bills Medicare for only the professional component of care rendered, those professional Medicare physician billings will be counted in calculating the bonus.
Radiopharmaceuticals will also be included in the basis of total allowed charges on which the 1.5% bonus is calculated.
For more details on payment, see MLN Matters Number: MM5558, page 5.
http://www.cms.hhs.gov/mlnmattersarticles/downloads/mm5558.pdf
2) Is the bonus based on all allowable Medicare charges billed under the Physician Fee Schedule or just billings for the measures reported?
The bonus will apply to total allowed charges for all covered professional services (as described above in #1), not just those charges associated with reported quality measure.
3) Are there only two measures (#10 and #11) for diagnostic radiologists? If there are less than three measures applicable to your practice, are you still eligible for the bonus program?
The PQRI program allows for participation if there are less than three measures applicable to your practice. If there are less than three, you must report on all measures applicable. For the 2007 PQRI program, there are two measures clearly identified for diagnostic radiologists. These measures are related to stroke care:
· Measure #10: Stroke and Stroke Rehabilitation: Computed Tomography (CT) or Magnetic Resonance Imaging (MRI) Reports
· Measure #11: Stroke and Stroke Rehabilitation: Carotid Imaging Reports
Radiologists should be aware of a few quality measures potentially applicable to their practices that could be reported in addition to #10 and #11. For example, “perioperative” Measures #20–23 could be applicable. These include surgical procedures that may be performed by a radiologist. Also the “osteoporosis” Measures #24 and #39–40 may be reportable if your services include Vertebroplasty or Kyphoplasty or Central Dual-energy X-ray Absorptiometry (DXA). If your practice performs such procedures: review the measures, look at the denominator coding (i.e., the ICD-9 and CPT Category I codes to see which are most applicable), and select a third measure to meet the reporting requirements and to increase reporting instances, and potentially increase your bonus.
Measures #39–40 may be reportable if your services include Central Dual-energy X-ray Absorptiometry (DXA). If your practice performs such procedures: review the measures, look at the denominator coding (i.e., the ICD-9 and CPT Category I codes to see which are most applicable), and select a third measure to meet the reporting requirements and to increase reporting instances, and potentially increase your bonus.
However, if these procedures are done infrequently, you do not need to report on the additional measures. The CMS PQRI validation process uses a common minimum threshold test; e.g., if a professional treated more than a “threshold” number of patients (or encounters), then that professional should be accountable for submitting the quality code(s) for that measure. For the 2007 reporting period, the common minimum threshold will not be less than 50 patients or encounters for each measure. So, if a radiologist has 35 eligible cases for the July 1–Dec. 31, 2007 reporting period, they do not need to report it. Please review the CMS Measure Applicability Validation Process for more detail using the following link. http://www.cms.hhs.gov/PQRI/Downloads/PQRI_Validation.pdf
4) Are Measures #10 and #11 only for inpatient imaging?
No, Measures #10 and #11 also apply to the outpatient and non-hospital setting. The measure specifications allow for services to be provided in settings such as an Emergency Department, freestanding clinic, or private office.
5) On Measure #10, how do we verify that the procedure was done within 24 hours of arrival to the hospital, if it is done in an outpatient setting or the ER?
Report Measure #10 “to the best of your knowledge.” If a patient is seen in a non-hospital setting (such as a physician’s office) o and has a CT with positive findings for stroke (using the ICD-9 codes in the specifications), the expectation is that the patient would be sent or transported to the hospital within 24 hours. Admission does not need to be verified; the specifications state “within 24 hours of arrival” at the hospital.
6) Is it true that, under Measures #10 and #11, there must be a definitive diagnosis of stroke, TIA, or intracranial hemorrhage on the radiologist’s claim to be reportable for PQRI? Can the measures be reported on claims with codes for signs and symptoms of those conditions?
Correct. The specifications currently state that a definitive diagnosis code is needed to include the case in the denominator. The ACR is participating in an AMA Physicians Consortium workgroup for development of PQRI measures for 2008. Broadening the clinical indications that “trigger” the stroke measures by linking with relevant ICD-9 codes is included in the group’s work plan. Visit the ACR Web site often for updates.
7) Measure #11 requires that the physician include direct and indirect reference to measurements of distal internal carotid diameter as the denominator for stenosis measurement. Can this be given as a percentage of stenosis? For example, the physician mentions an 80% stenosis of the internal carotid in the report?
Yes, if the stenosis is above 30%, the actual percentage or range should be included in the report. Additionally, a statement or a short note should be made, indicating that the degree of stenosis was obtained using measurements of distal internal carotid diameter (directly or indirectly) as the denominator for stenosis measurement. If you use the North American Symptomatic Carotid Endarterectomy Trial (NASCET) method, you can just state that this method was used.
8) What does "direct or indirect" mean for Measure #11, as referenced in the preceding question? Is there an example of preferred language for the report?
The measure requires the radiologist to use a standardized method for stenosis quantification based on measurements of distal internal carotid diameter as the denominator. Direct measurements may be done using MR/CT; indirect methods will likely be used for duplex ultrasound studies. Having velocity parameters correlate to the residual internal carotid lumen, with methods based on the distal internal carotid lumen, is an equivalent validating method and can be stated as such in the report. The comparative measurements are not made as part of the carotid ultrasound. The diameter stenosis range reported based on the velocity measurements should correlate with angiographic measurements using a method such as NASCET (as opposed, for example, to representing an area stenosis or a diameter stenosis related to the carotid bulb).
A short note can be made in the final report, such as:
“Severe left ICA stenosis of 70-80% by NASCET criteria” or
“Severe left ICA stenosis of 70-80% by criteria similar to NASCET” or
“70% stenosis derived by comparing the narrowest segment with the distal luminal diameter as related to the reported measure of arterial narrowing” or
“Severe stenosis of 70-80% — validated velocity measurements with angiographic measurements, velocity criteria are extrapolated from diameter data as defined by the Society of Radiologists in Ultrasound Consensus Conference Radiology 2003; 229;340-346.”
The references below may be useful to the radiologist in reporting stenosis in this way.
9) Is Measure # 74, Radiation Therapy for Invasive Breast CA after Conservative Surgery, appropriate for radiation oncologists to report (versus primary care physicians)? If so, what G-codes are appropriate for reporting?
Yes, radiation oncologists may report this measure if providing services, as outlined in the specifications, to patients with invasive breast cancer undergoing radiation therapy.
Applicable G-codes for this measure:
G8379: Radiation Therapy Recommended
G8378: Radiation Therapy not Recommended for Documented Reasons
G8383: Radiation Therapy not Recommended
See specifications for more detail on the G-codes. CPT II codes for these measures may be available in the near future.
10) Do all physicians in a practice participating in the PQRI need to meet the 80% reporting threshold for each applicable quality measure?
No. Successful reporting and bonus calculation is determined by CMS at the individual physician level, using the reported National Provider Identifier (NPI). Thus, physicians in a practice who do not participate in the PQRI or who do not meet the 80% reporting threshold, do not impact bonus payouts to practice members who do meet CMS PQRI reporting requirements. The 2007 PQRI bonus payouts for individual practice members will be aggregated and paid in a single check to the practice’s Tax ID # (TIN). CMS will, however, provide feedback reports on physician PQRI reporting patterns to the individual provider. Physician practices will need to devise a method for dividing bonuses as appropriate to each physician who participated and met CMS’ PQRI reporting requirements.
11) Is it a requirement to fill out the PQRI data collection worksheets on the CMS Web site for each and every patient and also maintain them?
No, it is not a requirement to fill out the PQRI data collection worksheets, and worksheets should not be submitted to CMS. Use is entirely voluntary. The worksheets were created to provide participants with a tool for ease of data collection. CMS describes the worksheets in the following manner:
2007 Data Collection Worksheets — Measure-specific worksheets that walk the user step-by-step through reporting for each measure. These worksheets may be used by the practice on a concurrent basis to collect PQRI data upon patient arrival for appointments.
· Identify the patients for whom PQRI measures and codes apply.
· Capture clinical information for translation into the administrative claim process.
· Integrate the measures into your practice.
· Maintain a copy of the worksheet to enable QI and tracking at the practice level.
12) Does a physician need 50 or more encounters or patients applicable to a measure to be eligible to participate in PQRI?
There is no minimum requirement to be eligible to report or participate. CMS will apply the minimum threshold test to those professionals who only submit quality data codes for one or two measures and may have potentially reported an additional measure. (See FAQ #3 above.)