PHYSICIAN VOLUNTARY REPORTING PROGRAM
Portions excerpted from CMS

Beginning this month, physicians will have a unique opportunity to participate in a new Medicare program. The PHYSICIAN VOLUNTARY REPORTING PROGRAM (PVRP) is based on capturing and reporting quality of care data - to identify the most effective ways for physicians to improve the health and function of Medicare beneficiaries. The PVRP is another reporting measure aimed at saving Medicare program money.

The PVRP will provide evidence-based quality measurment of patient care. Advanced care will prevent chronic disease complications, avoiding preventable hospitalizations, and improving the quality of care delivered.

According to CMS, claims with dates of service on or after January 1, 2006, carriers shall use the following new MSN message when denying the PVRP G-codes (G8006 through G8186) billed with $0.00 or billed with an amount:

The EOMB the patient receives will state: This code is for informational/reporting purposes only. You should not be charged for this code. If there is a charge, you do not have to pay the amount.

According to CMS, physicians who opt into the PVRP would begin reporting quality data and be able to receive feedback on their performance, as well as to provide input on how quality reporting can be improved and made even less burdensome. These steps are an important part in enabling CMS to provide better support for physicians' efforts to deliver high-quality care.

With Pay-for-Performance initiatives on the horizon, the PVRP is excellent preparation for the future. For this reason, CMS is committed to the development of reporting and payment systems that will support and reward quality. Ultimately, physician bonus programs will be tied into quality measures and providing these services to the beneficiary.

In serving the greater population as well as Medicare beneficiaries, CMS has also developed several quality initiatives that provide information on the quality of care across different settings, including hospitals, skilled nursing facilities, home health agencies, and dialysis facilities for end stage renal disease. The quality initiatives aim to empower providers and consumers with information that would support the overall delivery and coordination of care, and ultimately to support new payment systems that provide more financial resources to provide better care, rather than simply paying based on the volume of services.

The PVRP would initiate the process by which physicians who choose to participate would begin reporting quality data and be able to receive feedback on their performance, as well as to provide input on how quality reporting can be improved and made even less burdensome. These steps are an important step in enabling CMS to provide better support for physicians' efforts to deliver high-quality care.

Reporting Infrastructure

CMS has developed the underlying infrastructure so that voluntary reporting of quality measures can begin is month, using the existing administrative system for physician claims.

While the usual source of the clinical data for quality measures is retrospective chart abstraction, data collection through this process can be burdensome. Consequently, the voluntary reporting program will focus on ways to obtain valid quality measures as efficiently as possible.

Electronic health records (EHRs) will greatly facilitate clinical data reporting and performance improvement in the future but its adoption is not currently widespread. CMS is working with physicians to achieve the goal of adopting EHRs in their offices, building on reporting based on the pre-existing claims based system will be used for reporting data under the PVRP. The utilization of a pre-existing reporting system will minimize the burden on physicians.

Physicians can begin providing voluntary information for constructing evidence-based quality measures for the Medicare population through a defined set of HCPCS codes (called "G-codes"), which are reported on the pre-existing physician claim form. These new codes will supplement the usual claims data with clinical data that can be used to measure the quality of services rendered to beneficiaries.

The G-codes are an interim step until electronic submission of clinical data through EHRs replaces this process. Medicare expects to work with some physician groups that have already adopted EHRs to assist with this transition.

Medicare's contracted Quality Improvement Organizations (QIOs) are helping physicians move toward a more dynamic and evolving public reporting and pay-for-performance quality improvement environment. In specific, QIOs are providing assistance to help physicians create systems so that the measures can be more easily reported.

Development of Measures

Measuring and evaluating quality requires the development of clinically valid quality measures. Effective measures for performance measurement, quality improvement, disease prevention, and public reporting should be valid, reliable, evidence-based, and relevant for consumers, clinicians and purchasers. In addition, such measures must be developed through open and transparent processes and implemented in a realistic manner with minimal burden on physicians so as not to discourage appropriate care.

The PVRP will begin to phase in quality performance measures that are consistent with these requirements. These 36 evidence-based clinically valid measures have been part of the guidelines endorsed by physicians and the medical specialty societies and are the result of extensive input and feedback from physicians and other quality care experts. Physicians recognize the importance of these measures for the management of their patients' care, providing CMS with a strong starting point for the voluntary program.

Additional quality measures are under development now and could be phased-in for reporting later in 2006.

Quality Measures

The 36 quality measures are arranged in sets of measures, with multiple G-codes in each set. The physician will report the appropriate G-code that represents the clinical services furnished with regard to a specific measure set.

Each measure set has a defined numerator (the appropriate G-code) and a denominator (specifically defined according to the appropriate services or condition), which will be used to calculate performance.

The objective of the PVRP is to help physicians obtain information they can use to improve quality and avoid unnecessary costs. Thus, CMS will provide feedback to physicians on their level of performance based upon the data submitted through this voluntary effort. This feedback may begin as early as summer 2006.

You can see the measure set and the associated G-Codes at: http://new.cms.hhs.gov/PhysicianFocusedQualInits/Downloads/PFQIPVRP_Gcode.pdf

Medicare Quick Tip

First level Medicare appeals are now called redeterminations. Using the telephone redetermination process will quickly resolve most claim detail corrections that are appealable denials. For most carriers the number of issues that can be reported per call is still limited to 3 claims per call. Common corrections via telephone are (MA01 ANSI Reason code) listed below:

Failure to bill for a certain item or service cannot be submitted over the telephone. In those cases you submit a new claim for items or services that were omitted.

Incorrect use of Modifer 25 & 59

The Office of Inspector General recently released two reports, shown below, that bear repeating to all providers. It would serve all practices well to conduct a coding audit of all modifier use. Not just 25 & 59.

You can bet that the Medicare Carriers will be auditing, whether you do or not. Find and correct your coding mistakes now.

Use of Modifier 59 to Bypass Medicare's National Correct Coding Initiative Edits (OEI-03-02-00771) http://www.oig.hhs.gov/oei/reports/oei-03-02-00771.pdf

Modifier 59 is used to indicate that a provider performed a distinct procedure or service for a beneficiary on the same day as another procedure or service. This modifier would allow the code pair to bypass the edit and both services would be paid. This inspection found that 40 percent of code pairs billed with modifier 59 in fiscal year 2003 did not meet program requirements, resulting in an estimated $59 million in improper payments. Specifically, modifier 59 was used inappropriately with 15 percent of code pairs because the services were not distinct from each other and with 25 percent of code pairs because the services were not adequately documented. This inspection also found that 11 percent of code pairs billed with modifier 59 in fiscal year 2003 were paid when modifier 59 was billed with the incorrect code. This billing error represented $27 million in Medicare paid claims. In addition, OIG found that most carriers did not conduct reviews of modifier 59 but those carriers that did found providers who were using modifier 59 inappropriately.

OIG recommended that CMS: (1) encourage carriers to conduct prepayment and postpayment reviews of the use of modifier 59 and (2) ensure that carriers' claims processing systems only pay claims with modifier 59 when the modifier is billed with the correct code. CMS concurred with these recommendations.

Use of Modifier 25 (OEI-07-03-00470) http://www.oig.hhs.gov/oei/reports/oei-07-03-00470.pdf

OIG conducted this study to assess the extent to which use of modifier 25 meets program requirements. Modifier 25 is used to allow additional payment for evaluation and management (E/M) services performed by a provider on the same day as a procedure, as long as the E/M services are significant, separately identifiable, and above and beyond the usual preoperative and postoperative care associated with the procedure. OIG found that 35 percent of claims for E/M services allowed by Medicare in 2002 did not meet program requirements, resulting in $538 million in improper payments. Modifier 25 was also used unnecessarily on a large number of claims, and while such use may not lead to improper payments, it fails to meet program requirements. OIG recommends that CMS work with carriers to reduce the number of claims submitted using modifier 25 that do not meet program requirements, emphasize that providers must maintain appropriate documentation of both the E/M services and procedures, and remind providers that modifier 25 should only be used on claims for E/M services. CMS concurred with OIG's recommendations.

Life After Coding in the Doctor's Office
Tyessa V. Howard, CMC

Coding at first was a struggle for me. It was not until I took my PMI certification class that the light bulb finally went on. "Oh, I said to myself, this is what I have been doing all of this time." But it was too late, by the time I had taken and passed my certification test (on the first try) and the light bulb had kicked in and, my position at work was phased out. I was now unemployed and had not gotten a chance to utilize the certification I had just earned.

Then in March of 2005, an unexpected opportunity opened up for me. I was hired as a part-time instructor at Sanford-Brown Institute in Middleburgh Heights, Ohio. Teach coding? Who me? I had just gotten my "coding niche" down and then let go. How could I teach others how to do something I had only just begun to understand? I had honed my skills through experience and had passed the certification exam, but could I teach this to others? Not only would I need to instruct students on how to pick the right code, but also explain the process for correctly selecting codes.

I was able to start out teaching allied health courses, but the day finally came when it was time for me to teach coding - to lead others to certification. I prepared myself. Even though I had the answer to every practice question the students would get, I proceeded to code every exercise/worksheet with them. When they asked me "Ms. Howard, how did you get that answer?" I wanted to be able to tell them. And as far as the students getting the method down to a science, it was a lot easier than I thought. I took the steps in my head I used to code problems, and translated them to the students, step by step, with them following along with me in the process-as if they were doing it themselves. It took no time for them to recognize that with a basic method, and the rules of each section of the CPT, they could code just about anything with complete success.

Soon, I realized that coding is like bike riding. Once you learn how to ride, you never forget. I find it so rewarding to share my knowledge with others - to build that confidence in them that I once lacked. I remember a student who always arrived at the correct code would still seem confused. "I don't understand," she said. And my response to her was, "You do understand, you just don't realize that you understand. Once you accept this, coding will seem a lot easier." I was speaking from experience.