The Centers for Medicare and Medicaid Services (CMS) is continuing the Physician’s Quality Reporting Initiative (PQRI) for 2008 after Congress opted to maintain the program in recent Medicare legislation. As in 2007, when CMS launched the program, physicians successfully reporting on an expanded set of 119 quality measures through claims submitted for services provided from Jan. 1 to Dec. 31, 2008, may earn a bonus payment, subject to a cap, of 1.5 percent of the total allowed charges for covered Medicare physician fee schedule services. The measure set includes the two breast cancer measures used in 2007 as well as five new prostate cancer measures that were collaboratively developed by ASTRO and AUA. ASTRO encourages participation in this program.
- Background on PQRI Measures and Reporting
- PQRI and Radiation Oncology Practices
- Additional PQRI Education Information
- PQRI Power Point Presentations
- PQRI Worksheets
- PQRI FAQs
Background on 2008 PQRI Measures
- An Overview of PQRI Measures
- 2008 Specifications
- PQRI Measure Validation Process
- 2007 PQRI Fact Sheet
Additional PQRI Educational Information
- PQRI MLN - Program Overview
- PQRI MLN - Coding and Reporting Principles
- Coding for Quality - A Handbook for PQRI Participation (Updated June 18, 2007)
- PQRI PowerPoint Presentation- Module IV - Dec. 12, 2007
- PQRI PowerPoint Presentation - Module I
- PQRI PowerPoint Presentation - Module II
- PQRI PowerPoint Presentation - Module III
- PQRI PowerPoint Presentation - Module IV
- 2008 PQRI National Provider Call PowerPoint Presentation (April 30, 2008)
Prostate Cancer
#101. Appropriate initial evaluation of patients with prostate cancer
#102. Inappropriate use of bone scan for staging low-risk prostate cancer patients
#103. Review of treatment options in patients with clinically localized prostate cancer
#104. Adjuvant hormonal therapy for high-risk prostate cancer patients
#105. Three-dimensional radiotherapy for patients with prostate cancer
Breast Cancer
#74. Radiation therapy recommended for invasive breast cancer patients who have undergone breast conserving surgery
#71. Hormonal therapy for stage Ic-III, ER/PR positive breast cancer
Here are answers to some frequently asked questions about the PQRI program. For additional information, please go to CMS’ Web site at www.cms.hhs.gov/PQRI.
Calculating Bonus Payments
What will my bonus payment be if I participate in the PQRI program?
If you meet the 80 percent reporting requirement, a 1.5 percent bonus would be applied to all your allowed Medicare charges from January 1 through December 31, 2008. For example, if you bill $200,000 to the Medicare program in a year, over six months you are likely to bill $100,000, so your maximum bonus payment would be $3,000.
How do I meet the 80 percent reporting requirement?
The 80 percent reporting requirement means that you must report on the measure for 80 percent of the patients who are eligible – not 80 percent of all your Medicare patients. For example, if you choose to report on Measure 74, “Radiation therapy recommended for invasive breast cancer patients who have undergone breast conserving surgery,” you would need to report on this measure for 80 percent of your breast cancer patients who are in the fee-for-service Medicare program.
Can I anticipate how much my bonus payment will be?
Yes. You can calculate the maximum bonus amount you will receive (assuming you meet all the requirements) by determining what your Medicare charges were for the first six months of 2007. Multiply that amount by 1.5 percent. This amount is likely to be your bonus payment amount for 2008. Bonus payments are expected to be made mid-2009.
I heard you needed to report on at least three measures to receive bonus payments. What about radiation oncology?
If a physician reports on one or two measures, CMS will validate that no other measures were applicable for that physician’s practice. CMS does not want eligible professionals to select additional measures so that they can report on three and thus has excluded several broadly applicable measures from the validation process (diabetes, falls, advance care plan, medication reconciliation, etc.)
In addition to the financial incentives, are there other advantages to participating in PQRI?
Yes. It is unclear what Congress will do to address the flawed SGR formula in the future, and any congressional action may include refinement or expansion of the PQRI program. Physicians who participate in this program will enjoy the benefits of participating in this pilot program and may be better prepared for future programs in this area.
Measure 74 - Radiation therapy recommended for invasive breast cancer patients who have undergone breast conserving surgery
The denominator includes all breast cancer patients. How do I identify my breast cancer patients who have had mastectomies?
This measure is only related to breast conserving surgery patients. For mastectomy patients, report G8378, “Clinician documentation that patient was not eligible candidate for radiation therapy measure.”
Measure 71 - Hormonal therapy for stage Ic-III, ER/PR positive breast cancer
I noticed that measure 71 is also related to breast cancer. Do I have to write the prescription for the tamoxifen or aromatase inhibitor to report on this measure?
No. You do not have to write the prescription in order to report on this measure.
I am not responsible for monitoring whether my patients are receiving tamoxifen or aromatase inhibitors. Must I report on this measure?
No.
Can I report on both measure 71 and 74 on the same claim for the same patient?
Yes, if appropriate.
For additional information and FAQs, please visit ww.cms.hhs.gov/PQRI.
2007 PQRI and Radiation Oncology Practices
On Wednesday, June 20, 2007, ASTRO hosted a conference call with Susan Nedza, M.D., from the Centers for Medicare and Medicaid Services. This conference call was dedicated to informing ASTRO members and their coding specialists about the PQRI program as it relates to radiation oncology. Below are the links to both the PowerPoint presentations and the audio file from this conference call. We hope this information is helpful to you as you consider participating in the PQRI program.
*UPDATE: Since the time of this call, we have determined that CPT code 55875 (Transperineal placement of needles or catheters into prostate for interstitial radioelement application, with or without cystoscopy) is no longer listed in the specifications for Measure 20 “Timing of antibiotic prophylaxis.” Because this CPT code has been dropped from this measure, you will not be able to report on Measure 20 for brachytherapy services. Thus, for the 2007 program, radiation oncology practices will likely be limited to the breast cancer measures (measure 74 and measure 71). We continue to work on additional measures to be used in the 2008 PQRI program.
Updated measure specifications: 2007 Physician Quality Reporting Initiative (PQRI) Measure Specifications [PDF, 812KB] - Updated 06/19/07.