By Lynn Berry, PT, CPC
Quality Resource and Usage Reports (QRURs) are the first reports to use performance measures that may be included in the Physician Feedback/Value-based Modifier Program the Center for Medicare & Medicaid Services (CMS) is proposing to begin in 2015.
The Value-based Purchasing (VBP) initiative, part of the Affordable Care Act of 2010, requires differential Medicare payments for physicians or physician groups based on the quality of care they furnish, as compared to the cost of that care. The driving concept behind VBP is that health care buyers, including consumers and third-party payers, should hold providers responsible for both the quality and the cost of care. To implement this concept, CMS will apply a yet-to-be-determined, value-based payment modifier (VBPM) to physician services billed under the Medicare Physician Fee Schedule (MPFS). By 2017, the VBPM will be applied to claims for most or all physicians who submit claims under the MPFS (see the accompanying information, “Value-based Payment Modifier Timeline”).
The QRURs are designed to:
- Make physicians aware of their resource use and total cost per beneficiary;
- Put forth the idea of being paid for both quality of care and the amount of resources expended;
- Inspire care coordination across various specialties; and
- Help work out the bugs with physician feedback before the program is initiated and your payments are affected.
In March 2012, CMS distributed 23,730 QRURs to physicians in Iowa, Kansas, Missouri, and Nebraska. The QRURs were derived from 2010 Physician Quality Reporting System (PQRS) claims data and claims-based reports for any physician in the above four states that billed at least one claim through the MPFS. They did not include PQRS measures reported electronically or through registries. The reports were confidential and for use only by the individual physicians, at that time. They were removed from the website July 13, 2012 and will be replaced by new reports containing 2011 data in the fall of 2012 for nine states (California, Iowa, Illinois, Kansas, Michigan, Minnesota, Missouri, Nebraska, and Wisconsin).
What QRURs Tell You
QRURs inform providers where they stand compared to other providers of the same specialty regarding quality measures reporting and the cost of care. CMS designated 28 quality measures and 13 sub-measures (41 total, including preventive care, cancer, diabetes, and heart conditions) to determine whether the beneficiary received the indicated treatment during 2010 for primary care and preventive services. The National Quality Forum (NQF) is working on additional measures for chronic diseases (asthma and chronic pulmonary disease) and other conditions (pneumonia and hip and knee replacements).
The QRURs separately identify services that the physician:
- Directed (the physician billed for 35 percent or more of all of the patient’s outpatient evaluation and management (E/M) visits;
- Influenced (the physician billed fewer than 35 percent of the patient’s outpatient E/M visits, but accounted for 20 percent or more of the professional cost of care); and
- Contributed to the (physician billed for less than 35 percent of the patient’s outpatient E/M visits and accounted for less than 20 percent of the patient’s total professional cost of care).
For each category, the actual Medicare costs of care were assigned per beneficiary, and were risk-adjusted by medical history and patient demographics. Percentages were provided for higher or lower cost per care, per physician, compared with peers and whether their quality of care was better than, equal to, or worse than average for the particular quality measures.
CMS provides the template used for the QRURs on its website.
CMS distributed the QRURs to a few states first, allowing these physicians to look at the overall quality of care received by patients they cared for using the PQRS measures noted, even though the physician might not have provided the measures him- or herself. It also allowed physicians to compare the number of PQRS measures they reported versus their peers, and provided them with an overview of the true total cost of care for each of their patients.
The QRURs also provided a way to analyze individual physician involvement with each of the patients treated. This type of data has not been previously available. It is hoped that physicians will use this data to think about the way they practice, and how they can coordinate resources with other physicians and hospitals to reduce overall costs. They can look at the reports and see where they excel in providing efficient care, and where they can make improvements in quality and/or cost by using resources better.
QRURs Foretell Value-based Reimbursement
A practice that currently is not using PQRS might want to consider which measures are applicable to their practice, and implement their use to show the quality of care they are actually providing as individuals. Remember: In 2015 there will be a payment penalty from CMS for not reporting quality measures.
The new proposed rule for the 2013 MPFS (CMS-1590-P) notes that participation in PQRS will affect the way in which the VBPM is applied.
For physician groups with 25 or more eligible professionals that have met satisfactory reporting criteria for PQRS, the value-based payment modifier would not affect payments (it would be set at 0.0 percent)—unless they choose an option to earn an upward payment adjustment for high performance, “high quality and low cost.” This option would, however, place the group at risk for a payment adjustment for poor performance, “low quality and high cost,” with a maximum downward payment adjustment of -1.0 percent, initially.
For those physicians that have not met PQRS reporting criteria, or do not participate in PQRS, their value-based payment modifier would be set at -1.0 percent, in addition to the -1.5 percent for non-participation in PQRS. CMS is seeking comment on whether this should apply to physicians in solo practice or groups with less than 25 eligible providers.
Over time, other measures will be included in the QRURs, such as Healthcare Effectiveness Data and Information Set (HEDIS) measures, Medicare EHR Incentive Program measures, and patient satisfaction scores. Another area in development is an “episode grouper” to include episode-based costs, including clinical-related data to apply to an episode of care (a specific period of time from the onset to conclusion of care). An example of this would be a hip or knee replacement surgery that includes all related services and costs for that episode (inpatient and/or outpatient surgery, physician visits, home health, rehabilitation, skilled nursing facility (SNF), etc.).
See the MPFS proposed rule of 2013 at: www.ofr.gov/OFRUpload/OFRData/2012-16814_PI.pdf
As new programs replace the existing fee-for-service (FFS) payment model, providers will need to pay more attention to the various demonstration projects and initiatives being started. It will take a lot of time and effort, but comments on the new models from current providers will aid Medicare in making provider-friendly choices in the future as they modify their system designs.
If your practice is in one of the four states, and you have received a report and wish to comment, you can email CMS at CMS_Medicare_Physician_Feedback_Program@mathematica-mpr.com, or participate by asking questions and providing feedback at any upcoming conference calls yet to be announced. CMS is enlisting your feedback now as they work to improve the process.
If your practice is not in the states where QRURs have been distributed, go to the CMS website to learn what is in store for you when your geographic area is accessed, and to ask questions or comment on ways to make the process more valuable. For more information, go to www.cms.gov/physicianfeedbackprogram.
You may also comment on the regulations for the VBPM found in the proposed rule at www.regulations.gov.
Learn the new acronyms. Join the discussion. Be a part of the process early in the game!
Lynn Berry, PT, CPC, had over 35 years of clinical and management experience before beginning a new career as a coder and auditor. She later became a provider representative for a Medicare carrier. She now has her own consulting firm, LSB HealthCare Consultants, LLC, furnishing consulting and education to diverse provider types. She is also a senior coder and auditor for The Coding Network and a pilot tester for CMS web-based training courses. She has held several offices in her local AAPC chapter and continues as one of the directors of the St. Louis West chapter.
September 1st, 2012
The future depends on the specificity that ICD-10 offers.
By Annie Boynton, BS, CPC, CPC-H, CPC-P, CPC-I, RHIT, CCS, CCS-P, CPhT
As Coding Edge went to press, Department of Health & Human Services (HHS) Secretary Kathleen Sebelius had just announced a proposed one-year delay of the implementation of ICD-10 to Oct. 1, 2014 from Oct. 1, 2013. Since February, when Centers for Medicare & Medicaid Service (CMS) Acting Administrator Marilyn Tavenner said CMS would “re-examine” the implementation timeline, there has been a lot of industry chatter regarding ICD-10. Many have been asking, “Where do we go from here?” While others, knowing there are hundreds of millions of dollars at stake, are pushing forward with implementation. This is a smart move. ICD-10 is coming, and we need to be ready.
What Should Practices Do About ICD-10?
At this point, there is only one viable option: Continue moving forward with implementation. Any practice that equates a “re-examination” with a “termination” is putting itself at significant risk. Physicians and practice administrators should carry on with ICD-10 implementation plans, keeping a watchful eye on the Oct. 1, 2013 mandate.
Much of the information regarding ICD-10 in the marketplace is full of doom and gloom, and often is based on inaccurate or anecdotal data. In fact, ICD-10 does offer physicians benefits.
Value-based Purchasing Relies on ICD-10’s Specificity
Value-based purchasing is one concept that is not often heard in the medical practice, but—as any doctor who has argued an unspecified or miscellaneous code will tell you—it is a concept essential to accurate reimbursement. Value-based purchasing enables more accuracy in payment, based on the specificity in the ICD-10 codes. For example, compare the following ICD-9-CM and ICD-10-CM fracture codes:
ICD-9-CM Fracture Codes:
813.5 Fracture of lower end of radius and ulna open
813.50 Fracture of lower end of forearm, unspecified
813.51 Open Colles’ fracture
813.52 Other open fractures of distal end of radius (alone)
813.53 Open fracture of distal end of ulna (alone)
813.54 Open fracture of lower end of radius with ulna
ICD-10-CM Fracture Codes:
S52.57 Other intraarticular fracture of lower end of radius
S52.571 Other intraarticular fracture of lower end of right radius
S52.571A Other intraarticular fracture of lower end of right radius, initial encounter for closed fracture
S52.571B Other intraarticular fracture of lower end of right radius, initial encounter for open fracture type I or II
S52.571C Other intraarticular fracture of lower end of right radius, initial encounter for open fracture type IIIA, IIIB, or IIIC
S52.571D Other intraarticular fracture of lower end of right radius, subsequent encounter for closed fracture with routine healing
S52.571E Other intraarticular fracture of lower end of right radius, subsequent encounter for open fracture type I or II with routine healing
S52.571F Other intraarticular fracture of lower end of right radius, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with routine healing
S52.571G Other intraarticular fracture of lower end of right radius, subsequent encounter for closed fracture with delayed healing
S52.571H Other intraarticular fracture of lower end of right radius, subsequent encounter for open fracture type I or II with delayed healing
S52.571J Other intraarticular fracture of lower end of right radius, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with delayed healing
S52.571K Other intraarticular fracture of lower end of right radius, subsequent encounter for closed fracture with nonunion
S52.571M Other intraarticular fracture of lower end of right radius, subsequent encounter for open fracture type I or II with nonunion
S52.571N Other intraarticular fracture of lower end of right radius, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with nonunion
S52.571P Other intraarticular fracture of lower end of right radius, subsequent encounter for closed fracture with malunion
S52.571Q Other intraarticular fracture of lower end of right radius, subsequent encounter for open fracture type I or II with malunion
S52.571R Other intraarticular fracture of lower end of right radius, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with malunion
S52.571S Other intraarticular fracture of lower end of right radius, sequela
The comparison of the code descriptions easily demonstrates the increased specificity in the ICD-10-CM code, and also demonstrates the greater incremental value of the ICD-10-CM code. This specificity will be an important part of value-based purchasing incentive programs in the future, and will help to more accurately demonstrate outcomes of care. Value-based pricing can help payers create reimbursement systems that are more targeted, which can mean more accurate reimbursement in the long term.
Importance of External Cause vs. Condition Codes
ICD-10 specificity is often the focus of media attention. One prominent example was the September 2011 Wall Street Journal article, “Walked into a Lamppost? Hurt While Crocheting? Help Is on the Way.” The article’s focus was on ICD-10-CM external cause codes. There is a code for an injury while crocheting (Y93.D1 Activity, knitting and crocheting), for being struck by an orca (W56.22XA Struck by orca, initial encounter), for being bitten by a duck (W61.61XA Bitten by duck, initial encounter), and even for sustaining injury while milking an animal (Y93.K2 Activity, milking an animal). But consider how often the average medical practice reports external causes in ICD-9-CM. The answer is rarely, and that is not likely to change much in ICD-10-CM.
Although the external cause and place of occurrence codes make for entertaining reading, the focus of specificity must be brought to the condition codes. For example, ICD-9-CM contains one code for male breast cancer, while ICD-10-CM has 19 codes to provide greater anatomic detail and to enable monitoring that has been impossible with ICD-9-CM. From a data, quality monitoring, and outcomes perspective, specificity counts.
Procedure Code Benefits
ICD-10 offers similar advantages on the procedure code side. ICD-10-PCS offers specificity that will be vital in analyzing outcomes or care. For example, in ICD-9-CM, there is a single angioplasty code (39.50 Angioplasty of other non-coronary vessel(s)). In ICD-10-PCS, there are over 800 angioplasty codes, each one with the vessel, location, method of approach, and device included in the code description. This means physicians and facilities will be able to more accurately represent the work they are performing; and that means, in time, we’ll see more accuracy in payment and pricing structures and incentive programs, as well.
Every Bit Helps
ICD-10-CM also supports reductions in administrative costs. Don’t scoff: The specificity in ICD-10 offers up real potential for reductions in medical record requests and administrative costs associated with copying and mailing records or supporting documentation. With the highest percentage of gross domestic product (GDP) allotted to health care of any country on the planet, the United States would benefit from even small reductions in administrative costs.
What’s the bottom line? Continue on the ICD-10 implementation path. Health care has always centered on change. Improving health care reimbursement and care delivery systems, while evolving scientifically and technologically, are not new concepts. If we truly seek better, more affordable health care, then quality improvement, documentation, and data analysis in the future will depend on the specificity that ICD-10 offers.
Let’s keep calm, and carry on.
Annie Boynton, BS, CPC, CPC-H, CPC-P, CPC-I, RHIT, CCS, CCS-P, CPhT, is the director of 5010/ICD-10 communication, adoption, and training for UnitedHealth Group. She also teaches at Mass Bay Community College and she is a developer and member of AAPC’s ICD-10 training team.
May 1st, 2012
Under contract with the U.S. Department of Health & Human Services (HHS), the National Quality Forum (NQF) recently added four efficiency measures that “could be combined with quality metrics as part of the Medicare value-based purchasing plan set to start in 2015,” American Medical News reports.
Two of the new measures evaluate relative resource use for patients with asthma and chronic obstructive pulmonary disease (COPD), and a third looks at total costs for treating pneumonia. The final measure focuses on total costs for hip and knee replacement.
These four measures join four others, endorsed in January, which include metrics to examine resource use for patients with diabetes and cardiovascular conditions, and total resource use and total cost of care for all patients.
The central concept of value-based purchasing in health care is that buyers should hold providers accountable for both the cost and quality of care. Value-based purchasing seeks to reduce inappropriate care and to identify the best-performing providers. Ideally, those providers and health care systems that provide the best care at the best cost would be rewarded with greater numbers of patients.
By measuring resources used, rather than raw costs only, the NQF “is aiming to give apples-to-apples comparisons of physician efficiency that are not distorted by geographic price variations,” American Medical News continues.
The American Medical Association (AMA), among other groups, supports value-based purchasing initiatives, but has expressed concern whether such a system could be implemented without penalizing doctors who treat the most difficult cases.
April 27th, 2012