March 2009




Government reviewing 2007 PQRI reports

by David Laber EyeWorld Staff Writer



Physicians that participated in the 2007 PQRI might receive back pay from CMS for discrepancies in the agency’s analysis of physician reports

Physicians that participated in the 2007 Physician Quality Reporting Initiative (PQRI) might receive some additional reimbursement money later this year, according to Centers for Medicare & Medicaid Services (CMS) spokesman.

In 2007, CMS implemented PQRI as mandated by Congress, and the program covered the second half of the year. Physicians that enrolled in the program received a reimbursement for their participation as long as they met the program’s requirements including successfully reporting 80% of cases for which measures were reportable.

Despite CMS rewarding about $36 million to participating physicians, many physicians who were eligible for the 2007 bonuses, did not receive the full amount for which they qualified. Following a CMS decision in December 2008 to revisit every unsuccessful case that was filed, these individuals should receive additional compensation in the third quarter of 2009.

Before the December 2008 CMS decision

Potential issues with PQRI reporting were apparent early on. As a result, the American Society of Cataract & Refractive Surgery (ASCRS) and the Alliance of Specialty Medicine had worked to get legislation introduced in the Senate and House of Representatives that required CMS to evaluate the 2007 PQRI before moving forward into 2008. However, that legislation never came up for a vote.

In October 2008, the American Medical Association (AMA) released survey results of 408 online surveys that found that about 60% of physicians rated the program as difficult, and only about 22% were able to download their feedback reports. Of those who were able to download the reports, less than 50% said the report was useful.

In addition to the AMA survey, some members of Congress also wrote letters to CMS officials on behalf of the medical community at the urging of the Alliance of Specialty Medicine, said Nancey McCann, ASCRS Director of Government Relations. (ASCRS serves as the chair of the Alliance’s Medicare committee.) In one such letter, Rep. Frank Pallone, Jr. (D-NJ), wrote on Oct. 29, 2008, that “50,000 physicians reported data during the second half of 2007 but did not receive bonus payments for their efforts … other physicians did receive bonus payments but expected the amounts to be higher.”

CMS audits 2007 PQRI

As 2008 approached its end, 2007 PQRI participants became increasingly frustrated with the initiative because the program’s feedback reports’ shortcomings and discrepancies in the amount of bonus money they thought they were going to receive compared to what money they actually received.

In December 2008, CMS released a report that evaluated the its 2007 report program on its Web site ( and came to some of the same conclusions. “Since we began accepting the quality data in July 2007 for the 2007 PQRI, we have identified and begun to remedy issues and questions raised about the 2007 PQRI results and feedback,” according to the December report. “CMS analysis … has identified a number of unanticipated issues we believe may have impacted the success of physicians and other professionals in meeting program requirements for reporting quality data. These issues … include claims-based reporting mechanisms issues, National Provider Identifier (NPI) numbers not being included on the claims forms, incorrect quality reporting data or claims submission errors and the content of the feedback reports.”

Compensating for technicalities

As part of the 2007 review, a CMS spokesman said they were particularly interested in identifying what caused physician problems. “By far the biggest reason for invalid reporting is that the quality data code submitted for a patient really didn’t apply to that patient,” the spokesman said. CMS was able to determine this was the biggest problem because of the frequency for which the Healthcare Common Procedure Coding System (HCPCS) code (or simply, the billing code) did not match with the quality data code (QDC) for the measure.

These errors could be the physician’s error in reporting, or a technicality due to the billing form, he said.

On the billing form, the physician must indicate a diagnosis that pertains to a billing code, and that is done with the diagnosis pointer; however, in another part of the billing form, several diagnoses are listed.

In some claims, physicians submitted all of the diagnoses, but they failed to point to a specific diagnosis. “We are going to modify our analytics to adjust for that. So for 2008 (and future years), instead of just looking at a diagnosis for which there is a pointer, we are going to take any diagnosis on the claim, and that will count for PQRI purposes,” he said.

This analytic will also be applied retroactively to the 2007 reports, he said. “We will look at all of the diagnoses on the claim and not just the ones with a pointer to them, determine if would that cause more valid quality data code submissions, and if so, that could lead to some doctors—and I’m confident it will lead to numbers of doctors that didn’t qualify in 2007 when we do a rerun—they will qualify.”

Another problem for physicians were split claims. The CMS spokesman said there was a requirement to send the QDC on the same claim as the payment of service claim. So if a patient came for an office visit for a condition, and the physician reported that measure, all of the information would be on the same claim, which includes the diagnosis, office visit, and the QDC. The problem arose, however, as a result of Medicare carriers splitting claims if the number of lines exceeded a certain number. Some practice billing offices were splitting claims before they reached the carriers.

The CMS spokesman said about 6% of the claims were rejected for this split, but those affected in 2007 will also receive a bonus in 2008 retroactively.

Additional changes to PQRI

Also included in the self-review were the maligned feedback reports. “The feedback reports did not have sufficient detail with regard to the reporting errors for the doctors to understand what the difficulty in terms of reporting was,” the CMS spokesman said.

Given the physician response, CMS decided to investigate the feedback reports. He said the feedback reports will be modified to be more useful for the physicians to explain why their QDC were not accepted.

One change that will not occur despite requests from the AMA, ASCRS, the Alliance for Specialty Medicine, and some Congressmen is the creation of an appeals process.

CMS works under the authority that Congress gives it, and Congress specifically prohibited appeals in the creation of PQRI. “There was a good reason Congress did that,” the CMS spokesman said. “If you think about it, there were 109,000 individuals that submitted quality data codes, so conceivably you could have an appeal for each one as to whether they qualified, and for those that did qualify, (there could be an appeal) for as to the amount of money they got.”

He added that by re-running the 2007 numbers, CMS is, in essence, performing an appeals process anyway.

Tips for accurate reporting

One practice that had success reporting its 2007 PQRI claims was the St. Luke Hospital, Tarpon Springs, Fla., said Kim Newby, the hospital’s business office manager. “I was told a lot of practices thought they were doing everything right, but when they got their PQRI money, it wasn’t near what they thought it should be, and ours was almost to the penny what we calculated it would come out to,” she said.

The key to their success was making only a slight change to their current billing review system.

“We came up with a system by marking fee tickets with billable diagnoses with a highlighter, which alerted the physicians and technicians that they needed to do the extra tests or ask the extra questions to make sure that they would qualify for the bonus,” Ms. Newby said. “We literally reviewed every fee ticket by hand to make sure that those with the qualifying diagnoses had the proper codes marked on them.”

While this may sound like a lot of extra work, she said that the individual who sorts the fee tickets, which was already done by date, physician and other parameters, the sorter would check to make sure the codes were marked properly and spot check to make sure they were keyed into the computer before sending the fee ticket to Medicare electronically.

“I honestly don’t believe it created all that much work,” she said. “I think it was part of a process that we already did because we already review every fee ticket because it is easier to fix it before it is sent to Medicare than after.”

Even still, there was a slight problem in that they did not receive their check as promptly as they should have. Apparently, an ophthalmologist who no longer worked at St. Luke received the check that was intended for the hospital, Ms. Newby said. The check was returned to Medicare, but after a couple months and several phone calls later, they did get their funds.

Contact Information

McCann: 703-591-2220,

CMS: Allison Henry, 202-690-6149,

Newby: 727-938-2020,

Government reviewing 2007 PQRI reports Government reviewing 2007 PQRI reports
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