May 31, 2011
Although anesthesiology has one of the highest rates of participation in the Physician Quality Reporting Initiative (PQRI, now the Physician Quality Reporting System or PQRS), the specialty also has one of the highest error rates in reporting—nearly 50 percent.
Looking at the types and frequency of reporting mistakes will help anesthesiologists avoid losing an expected PQRS bonus payment. Fortunately the threshold for qualifying for the bonus dropped from valid PQRS Quality Data Codes (QDCs) submitted for 80% of eligible cases to just 50% this year. It is nonetheless important to improve the accuracy of PQRS reporting, especially since most anesthesiologists perform only one or two PQRS measures, because successful participation in the PQRS is used increasingly to judge physicians’ relative “quality.”
According to the 2010 2nd Quarter QDC Error Report by Specialty, the most recent detailed performance data published by CMS, nuclear medicine (95.80%), oncology/hematology (95.69%) and cardiology (94.53%) were the specialties with the highest percentages of valid QDC submissions. The overall physician rate was 81.62 percent. Anesthesiology reported valid QDCs in only 52.44% of cases. Nurse anesthesia fared even more poorly, with a 49.24% success rate. The table below shows the types of errors tracked by CMS and the performance statistics for anesthesiology and total physicians. We are not including nurse anesthetist data for reasons of space, but we refer readers to the full CMS report.
The great majority of the anesthesiologists’ errors involved the selection of an incorrect procedure code (CPT or HCPCS). In other words, the CPT code reported on the claim was not among the acceptable denominator codes. The procedure identified on the claim was not eligible for the particular quality measure, i.e., QDC. This happened with 45.86% of all 2,262,233 QDCs reported.
The procedure was not eligible for the QDC in only 9.55% of the claims submitted by the combined total of physicians. Several factors might account for the much greater frequency of this error on anesthesiologists’—and CRNAs’—claims. First, the specialty to which the physician is assigned comes from the specialty “taxonomy” code used when the physician enrolled with Medicare. The specialties that apparently submitted at least one valid QDC for the original anesthesia quality measure, Timing of Prophylactic Antibiotics—Administering Physician (Measure #30) included the following in addition to anesthesiology and nurse anesthesia: Allergy/Immunology, Cardiology, Chiropractor, Critical Care, Dentist, Emergency Medicine, Family Practice, General Practice, General Surgery, Health Center, Internal Medicine, Neurosurgery, Nurse Practitioner, OB/Gynecology, Orthopedic Surgery, Other Non-Physician Provider, Other Physician, Pathology, Pediatrics, Physical Medicine, Physician Assistant, Plastic Surgery, Psychiatry, Pulmonary Disease, Registered Nurse and Urology. Really? A psychiatrist or allergist billing a 0XXXX anesthesia code, and also administering the prophylactic antibiotic within one hour before the surgeon makes the incision? It is hard to imagine this happening even once, although with more than 7,000 claims being filed with Medicare every minute, 24/7, it isn’t impossible.
More likely is a surgeon’s having confused Measure #30 with Measure #20, Timing of Antibiotic Prophylaxis—Ordering Physician, and thus reporting #30 along with an orthopedic or otolaryngology code. That surgical code would not be in Measure #30’s denominator. The result would be an invalid QDC—one of the 45.86% errors associated with the specialty of anesthesiology.
Similarly, anesthesiologists may have mistakenly submitted the QDC for ordering the antibiotic, QDC #20. (Interestingly, nurse anesthetists were not among the providers who submitted a valid QDC for Measure #20, although nurse practitioners and registered nurses were.) This measure was in the top 25% of all QDCs submitted and yet only 7.34% of those QDCs were valid, according to the companion CMS Quality-Data Code Submission Error Report. More than 91% of the #20 QDCs had an incorrect diagnosis code. Another 19,041 (1.25%) contained only the QDC and had no associated CPT code at all.
To a considerable extent, however, anesthesiologists successfully reported the two major PQRS measures identified with the specialty: 78.61% of the 1,502,396 QDCs for administration of antibiotic prophylaxis, Measure #30, were valid, as were 93.23% of the 541,116 QDCs for Perioperative Temperature Management, Measure # 193.
Anesthesiology was also among the specialties reporting at least one valid QDC for many non-anesthesia procedures, for example Low Density Lipoprotein Control (Measure #2), Aspirin at Arrival in the Emergency Department (#28), Consideration of Rehabilitation Services (#36), ECG Performed for Non-Traumatic Chest Pain (#54) and Vaccination for Patients ? 50 Years Old (#110). Again, this may be more an artifact of the unverified designation of an enrolled physician’s specialty than of credentialed anesthesiologists branching out in unconventional directions.
Anesthesiologists should take care, however, to avoid reporting 15 or more PQRS measures like those listed above, or Screening Mammography (#112) in a calendar year, or 8 or more in a six-month period. Recall that the PQRS incentive requires physicians to report on at least three measures, unless fewer than three apply to their individual practices. Most anesthesiologists are reporting one or two, but not three, measures and qualify for the incentive payment. If an anesthesiologist reports the threshold number of 15 or 8 instances of a given QDC, but does not report that QDC on 50% of his claims for the underlying visit or other non-anesthesia service in the measure’s denominator, he might jeopardize the bonus he would have secured by limiting himself to the antibiotic prophylaxis or normothermia measures.
Reviewing the tables in the two CMS papers referenced above, it seems rather easy to make data entry errors in reporting QDCs. The papers provide a list of the errors that cause a physician’s PQRS profile to look different than the reality: patient age or gender mismatches, QDC and CPT or ICD-9 code mismatches, failure to identify the denominator procedure, or otherwise to fail to meet all the requirements for the particular measure. This list of errors might be useful as the basis for an internal audit.
More Practice Management Information from ABC: Monthly Q & As
We recently launched a new monthly question and answer feature on our website. The questions will appear in the publications in which we advertise: Anesthesiology News, Anesthesiology, and the ASA Newsletter. Come to www.anesthesiallc.com to find the answer. Soon we will be adding commenting capabilities so you can join in a discussion about the latest news and information posted.
April's question - Can a nurse practitioner perform the post-anesthesia evaluation?
No. The Medicare Conditions of Participation for Hospitals require that an individual authorized to administer anesthesia–an anesthesiologist, an anesthesiology resident or other medical doctor, a nurse anesthetist or an anesthesiologist assistant–complete and document the post-anesthesia visit for inpatients.
May's question - What is the “company model?”
The “company model” is an arrangement where surgeon owners of an ASC try to employ anesthesiologists in a separate company whose only purpose is to circumvent the prohibition on kickbacks for referrals. See ASA’s letter to the OIG dated February 24, 2011, requesting a Special Fraud Alert warning the ASC industry that attempting to take a portion of the anesthesiologists’ fees through the “company model” is illegal.
June's Question: For which procedures can you not report fluoroscopy separately?
Please visit the website to see June’s answer.
With best wishes,
Tony Mira
President and CEO
