ACR Radiology Coding Source™ for March-April 2013 Q and A

Q: For PQRS Measure #76, does the physician need to mention each specific element of maximal sterile technique, or is it acceptable to state “all elements of maximal sterile technique were followed?”

A: Measure #76 reports the “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 [cap AND mask AND sterile gloves AND a large sterile sheet AND hand hygiene AND 2% chlorhexidine for cutaneous antisepsis (or acceptable alternative antiseptics per current guideline)] followed.” The instructions of the measure state that it is to be reported each time a CVC insertion is performed during the reporting period, using CPT Category II code 6030F. Consistent documentation is advised in order to receive credit for the maximum number of patients, though guidelines are not given.

Please note that the measure does not require the compliance statement to be documented in the final report or patient chart. The physician reporting CPTII 6030F is attesting that the maximal sterile barrier technique was used. Having a written policy or procedure indicating that the technique is to be used, describing each specific element will support attestation in the event of an audit.

Q: Measure #265, Biopsy Follow Up, states that it is only reportable via registry. If we are reporting via claims for other measures, can we also report on Measure #265?

A: The Centers for Medicare and Medicaid Services will provide an incentive payment based on a single reporting mechanism only. Claims-based measures and registry-based measures will be evaluated as mutually exclusive entities and the incentive awarded to the reporting mechanism resulting in the best outcome. Measures reported through different mechanisms will NOT be combined to assess successful PQRS participation.

Q: What constitutes the “direct” or “indirect” reference to measurements for carotid stenosis as it refers to IR, MRA and CTA procedures included in PQRS Measure 195, Stenosis Measurement in Carotid Imaging Studies? If a direct angiographic modality is used, does a validating method need to be additionally documented?

A: Cerebral angiogram and other angiographic modalities such as magnetic resonance angiography (MRA) or computed tomographic angiography (CTA) all provide direct angiographic stenosis calculations. A direct method (using North American Symptomatic Carotid Endarterectomy Trial) OR an equivalent validated method needs to be documented when performing the measurement, but not both.

Measure #195, Stenosis Measurement in Carotid Imaging Studies, 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 with cerebral angiogram or other angiographic modalities such as MRA or CTA; 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.”

Q: Can two measures be reported on the same claim? If they cannot be reported on the same claim, how do you handle Measure 146, Inappropriate Use BIRADS 3, and Measure 225, Reminder System for Mammograms, for screening mammography?

A: Yes, more than one measure can be reported on a claim. CPT Category II codes can be entered on the same claim (under the same diagnosis codes). Each row can only contain one Category II code. If the measure denominator is based on a diagnosis code and CPT Category I code, those codes for both measures must be on the claim in order to report both Category II codes.

Q: Our mammography reminder letters inform patients of the date of their last mammogram and tells them it is time to call for an appointment, but they do not include an actual “target date.” Is this satisfactory for reporting Measure #225, Radiology: Reminder System for Mammograms?

A: Yes, reminder letters that inform patients of the date of their last mammogram and state it is time for them to schedule an appointment meet the requirements of Measure #225. Measure #225 requires that the reminder system determine the target due date for the next exam in order to create a letter in the appropriate time frame according to the patient’s needs. The measure numerator states: “Patients whose information is entered into a reminder system with a target due date for the next mammogram” and [the reminder system] includes the following element requirements (at a minimum):

Patient identifier

Patient contact information

Date(s) of prior screening mammogram(s) (if known)

Target due date for the next mammogram

The numerator quality-data coding options for satisfactory reporting include CPT II 7025F or 7025F with 8P (the patient information has NOT been entered into a reminder system and the reason is not otherwise specified).

Additionally, note that the measure does not require that information to be included in a final report. It would be practical to have a written policy or procedure that states all patients receiving screening mammograms have the specific information entered into a system to allow followup and reminder letters, in case of an audit.

Q: For Measure #225, will all mammography providers be penalized if they don't have a system in place by 2015?

A: Penalties are not assigned for each individual measure, but rather as a reflection of participation in PQRS reporting. An eligible provider (EP) who is able to report on at least one measure for one patient in 2013 will avoid the penalty payment adjustment in 2015. To achieve an incentive payment, an EP must report on three measures (for 50 percent of the eligible claims population or 80 percent of the eligible registry population). If three measures are not available to the physician (i.e., they do not perform the services related to the measure), they should report on as many as possible (one to two measures) for the 12-month period in order to be eligible for the incentive. PQRS allows for flexibility in the selection of measures reported by each individual physician.

Q: Will the same measures chosen to be applied for the PQRS incentive also be applied for assessment of a penalty payment?

Yes, the incentive and penalty payments are both calculated from the same 12-month period of PQRS reporting (or absence thereof). The analysis of data for measures chosen will apply to the potential for an incentive payment as well as the possibility for a payment reduction (penalty).

If your question is not found here, please visit the PQRS section of the ACR website or send email to P4Pquestions@acr.org.

Q: Does Measure #225 apply to hospital-based radiologists who use the hospital’s reminder system?

A: It is appropriate for physicians to report on measure #225 even if they use a hospital-based reminder system. Please ensure that the reminder system includes the criteria as listed in the 2011 Physician Quality Reporting System Measure Specification as follows:

Numerator Instructions: The reminder system should be linked to a process for notifying patients when their next mammogram is due and should include the following elements at a minimum: patient identifier, patient contact information, dates(s) of prior screening mammogram(s) (if known), and the target due date for the next mammogram.

In order to report this measure correctly, please report on patients that meet the denominator criteria as listed in the measure specification.

Q: Why does the Physician Quality Reporting System (PQRS) nuclear medicine bone scan Measure #147, Correlation of Bone Studies, require the radiologist to document correlation with relevant existent exams if the bone scan is normal?

A: Radionuclide bone imaging plays an integral part in tumor staging and management. The majority of bone scans are performed in patients with a diagnosis of malignancy, especially carcinoma of the breast, prostate gland and lung. This modality is extremely sensitive for detecting skeletal abnormalities. Numerous studies have confirmed that it is considerably more sensitive than conventional radiography for this purpose.

However, the specificity of bone scan abnormalities can be low since many other conditions may mimic tumor; therefore, it is important that radionuclide bone scans are correlated with available, relevant imaging studies. Existing imaging studies that are available can help inform the diagnosis and treatment for the patient. Furthermore, correlation with existing radiographs is considered essential to insure that benign conditions are not interpreted as tumor.

While there are no formal studies on variations in care and how often correlation with existing studies is performed, there is significant anecdotal information from physicians practicing in the field that there is a gap in care and that correlation is not occurring frequently when images are available.

Literature suggests that as many as 30 percent of radiology reports contain errors, regardless of the imaging modality, radiologist’s experience or time spent in interpretation. Evidence also suggests that radiology reports are largely nonstandardized and commonly incomplete, vague, untimely and error-prone and may not serve the needs of referring physicians. Therefore, it is imperative that existing imaging reports be correlated with the nuclear medicine bone scintigraphy procedure to ensure proper diagnosis and appropriate patient treatment.