EHealth Made Easy | Reporting Experience

Physician Quality Reporting Initiative 2007 Reporting Experience December 3, 2008 CMS PQRI 2007 Reporting Experience Only 52% Received a Bonus 2007 PQRI Participation Summary and Earned Incentive Payments Nationally, 109,349 NPI/TIN combinations (15.8 percent of eligible NPI/TIN combinations) submitted at least one QDC. To be validly submitted on the claim, the QDC reported must apply to the patient according to the measure specifications (age, gender, diagnosis, and procedure). In addition, the claim must include the rendering professional’s NPI, and otherwise comply with PQRI QDC submission business requirements. Of those 109,349 NPI/TIN combinations: 101,138 (92.5 percent) validly submitted at least one QDC; 70,207 (64 percent) validly reported quality data on 80 percent of eligible cases for at least one measure; however, may not have earned an incentive because they did not meet the criteria for satisfactory reporting; 56,722 (52 percent) earned an incentive payment (met criteria of satisfactory reporting by reporting data on 1 - 3 applicable measures for 80 percent of applicable cases); and 770 (1 percent) were subkect to the cap; the rest qualified for the full 1.5 percent incentive payments. A total of 14,089,837 QDCs were reported: 51.6 percent were submitted validly (7,266,783); and 48.4 percent were submitted invalidly (6,823,054). PQRI Quality Data Reporting is Complex! Listed below are the situations in which QDC or measure submissions were considered invalid. Each of the reasons under items number 1 and 2 below for invalid QDC submissions is included in the 48.4 percent of invalid submissions noted above. The reasons listed for invalid QDC submissions, however, are not mutually exclusive. More than one reason for invalidity may apply to a submitted QDC, so the percentages may not add up to 48.4 percent. Had the invalid submission been valid, it would be expected that additional professionals may have qualified for an incentive payment for 2007. It is not possible to determine the numbers of such professionals that may have qualified. 1. Not Adhering to Measure Specifications: The causes for specific invalid reporting links to business rules numbers 2, 3, and 9 on pages 7 and 8 of this report. Valid reporting of quality data could only be determined if the measure specifications were adhered to. Based on our review, the following invalid quality data submissions were caused by EPs failing to adhere to measure specifications in submitting QDCs and denominator codes, which were established through a board consensus process that included the physician community. The 2007 PQRI measure specifications are available for review on the PQRI website at www.cms.hhs.gov/PQRI. The quantity and percentage of QDCs that would have been affected are listed. Incorrect HCPCS denominator code: 18.9 percent (2,662,023 QDCs). In this example a QDC is submitted and a HCPCS denominator code is submitted, but the HCPCS code submitted was not one that was appropriate for the measure. - Each measure requires submission of a HCPCS (procedure or service code). A measure that had a high reporting error due to this reason was measure #30 (Perioperative Care: Timing of Prophylactic Antibiotic – Administering Physician). This was the only measure that required the submission of a CPT II code for the denominator rather than a HCPCS procedure or service code. Incorrect diagnosis code: 13.9 percent (1,963,196 QDCs). In this example, a QDC was submitted and a diagnosis code was submitted, but the diagnosis code was not the diagnosis appropriate for the measure being reported. - Circumstances where the incorrect diagnosis reporting rate was high were measures that required multiple diagnoses, e.g., #5 (Heart failure: Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD)), and #8 (Heart Failure: Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction). Causes of Invalid Quality Data Submission or Reporting Incorrect HCPCS and diagnosis code: 7.2 percent (1,019,422 QDCs). In this example, a QDC is submitted and a HCPCS code and diagnosis code are submitted, but neither the HCPCS nor the diagnosis code is contained in the reporting denominator for the applicable measure’s QDC. - A measure that had a high reporting error due to this reason was measure # 7, Beta-blocker therapy for coronary artery disease patients with prior myocardial infarction (MI). This measure required the reporting of an ICD-9 diagnosis code to identify patients with a diagnosis of coronary artery disease and a diagnosis of MI and a CPT service code for the denominator. Incorrect age: 6.0 percent (843,689 QDCs). In this example, the QDC is submitted for a patient outside of the age parameters for the measure. - Many measures are limited by age parameters. Those that only apply to the pediatric or younger adult age population experience very high error rates, e.g., Measures #53 (Asthma; Pharmacologic Therapy for Ages 5 to 40), and #64 (Asthma Assessment for Ages 5 to 40). Even those with upper age ranges of age 75, such as the diabetes measures #1 (Hemoglobin A1c Poor Control in Type 1 or 2 Diabetes Mellitus for Ages 18 to 75), #2 (Low Density Lipoprotein Control in Type 1 or 2 Diabetes Mellitus for Ages 18 to 75), and #3 (High Blood Pressure Control in Type 1 or 2 Diabetes Mellitus for Ages 18 to 75), experienced large error rates. Incorrect gender: 0.2 percent (22,424 QDCs). In this example, the QDC was submitted for a patient of the wrong gender for the measure. - Only a few measures are limited by gender, e.g., measure #39 (Screening or Therapy of Osteoporosis for Women Aged 65 Years and Older). Claims Submission/Split-Claims Errors: Claims submission and/or split-claim errors link back to business rule number 2 on page 7 of this report. Valid reporting could only be determined if the QDC was submitted on the same claim as the billing and diagnosis code(s) that are associated with the measure. In searching for technical issues that may explain a portion of the invalid QDC submissions we separated out those QDCs that were submitted invalidly because of missing HCPCS codes, not just an incorrect HCPCS code as described above. This was done because a missing HCPCS code could be an indicator that the claim was split (i.e., separated into smaller claims) prior to submission or during the processing of the claim by the carrier/MAC; the initial single claim therefore would have arrived in the claims data file used for the PQRI determinations as multiple claims. We found that a total of 6.3 percent of QDCs had no HCPCS on the claim. When claims are split prior to submission to the carrier/MAC by the EP’s billing software or clearinghouse software, there is no identifier on these claims to indicate that they were originally part of a single claim. For analysis purposes, it was assumed that these split claims were separate, unrelated claims. However, to identify these circumstances we reviewed all claims containing only QDCs to determine if there were other claims with HCPCS codes that also were for the same beneficiary, date of service, TIN and NPI. The 6.3 percent of QDC submissions with no HCPCS on the claim can be further broken out as: Only QDC on claim: 5 percent (700,201 QDCs). In this example, a QDC was submitted on a claim, but there was no HCPCS code on the claim to determine the appropriate denominator population for the measure. All measures must contain at least one HCPCS code in the reporting denominator. QDC and incorrect diagnosis code on claim: 1.3 percent (184,519 QDCs). In this example, a QDC was submitted on a claim, but there was no HCPCS code on the claim and the diagnosis code reported was not the diagnosis code required for the measure’s denominator population. All measures must contain at least one HCPCS code in the reporting denominator. However, not all measures require a diagnosis code to determine the denominator population. No NPI on the Claim: Requiring an NPI on the claim links back to business rules number 4 and 5 on pages 7 and 8 of this report because the statute requires analysis or determination of satisfactory reporting at the individual EP level, and the NPI is the only reliable identifier at the EP level. In some cases the business rule requiring the NPI for valid quality data submission and analysis had an impact on the analysis and determination of whether or not an EP satisfactorily reported. A total of 12.2 percent or 1,711,975 QDCs reported did not include an NPI on the line on which the QDC was reported. Lack of a NPI on the claim or line may have been caused by the EP’s failure to include it on the claim or line or errors made by the EP’s billing software or clearinghouse software. A discussion of the NPI issue follows. The absence of an NPI affects both acceptance of the QDC and inclusion of associated charges on claims for calculation of incentive payment amounts, based on the requirement that both satisfactory reporting and the incentive payment amounts be determined at the individual level. QDCs submitted on a claim without an NPI are not attributed to the individual and are not counted as valid reporting. Similarly, charges submitted on a claim without an NPI are not attributed to an individual and therefore cannot be considered in the calculation of an incentive payment. Professionals who qualified for the 2007 incentive payment were eligible for the incentive payment even if they submitted additional QDCs without an NPI. On the other hand, the absence of an NPI on any claim would mean that the associated charges would not be captured for the purpose of determining the estimated total allowed charges on which the incentive payment is based. In reviewing the missing NPI issue we tracked representative cases from the claim all the way through the claims warehouse and to the database used for the satisfactory reporting determination and the incentive payment calculation. We have not encountered mishandling of the NPI once the NPI was received by the carrier/MAC in the appropriate place on the claim (i.e., as the rendering NPI for the HCPCS and QDC line item codes). On the other hand we have encountered situations where EPs’ electronic data interface software or clearinghouse processes led to NPIs not being submitted or being incorrectly submitted, such as transposing the NPI from the line item to the referring NPI field. In these circumstances the requirement that the NPI appear on the line item for the HCPCS and QDC was not met. The missing NPI issue affected approximately 12 percent of QDCs that were submitted and which therefore were not considered as valid reporting. Other errors discussed previously may also have been present, so it is not possible to determine the degree to which the associated QDC would have been valid had the NPIs been present. We are also unable to determine the impact on the amount of incentive payments that professionals would have received had the NPI been reported on the line with HCPCS charges for these professionals. The requirement that both qualifications for an incentive and the amount of the incentive be determined at the individual professional level prevents us from attributing either the QDCs reported or the charges submitted to an individual and to consider these for PQRI. Get Adobe Flash player