January 12, 2009

This year, as in 2007 and 2008, the Physician Quality Reporting Initiative does not contain any measures designed specifically for the subspecialty of pain medicine. Although the total number of PQRI measures has increased to 153, quite a few subspecialties are not yet represented.

Does that matter for anesthesiologists who provide pain management services? It does, but only under a very narrow set of circumstances. Recall that the PQRI bonus is based on whether the individual physician successfully reports on a minimum of three measures, unless fewer than three of the PQRI measures apply to that physician’s practice. If fewer than three apply, reporting on two applicable measures (or even one, if no other measures apply) will suffice – and a physician who performs both surgical anesthesia and pain medicine services may qualify for the bonus by reporting Measure #30, “Timing of Prophylactic Antibiotic – Administering Physician,” plus Measure #76, “Prevention of Catheter-Related Bloodstream Infections (CRBSI) – Central Venous Catheter Insertion Protocol,” in 80% of all eligible cases.

There are some anesthesiologists and other specialists, however, who strictly limit their practices to chronic pain medicine and who would like to earn the 2% PQRI bonus. These physicians have the option of choosing three (or more) general medical care measures that can be reported together with evaluation and management (E/M) services, i.e., visits and consults. (Most of the measures below may also be reported with psychiatric, behavioral, nutritional or occupational therapy codes, but we do not know of pain practices routinely providing those services.)

Three relevant measures that we believe pain specialists could report with some minor adaptations to their documentation routines are the following:

1. Measure #47, Advance Care Plan

Description: Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan

The physician must report this measure at least once for all eligible patients aged 65 years and older seen during the reporting period., i.e., 2009. Eligible patients are those for whom the pain physician submitted a claim for any of the following CPT™ codes:

• 99201, 99202, 99203, 99204, 99205 (office-new patient),
• 99212, 99213, 99214, 99215 (office-established patient),
• 99218, 99219, 99220 (initial observation care),
• 99221, 99222, 99223 (initial inpatient),
• 99231, 99232, 99233 (subsequent inpatient hospital care),
• 99234, 99235, 99236 (observation or inpatient hospital care), or
• 92911 (critical care)

To report Measure #47 with one of the above E/M codes, the physician would submit one of the following quality codes:

• CPT II 1123F: Advance Care Planning discussed and documented; advance care plan or surrogate decision maker documented in the medical record
• CPT II 1124F: Advance Care Planning discussed and documented in the medical record; patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan
• CPT II 1123F–8P: Advance care planning not documented, reason not otherwise specified

2. Measure #114, Preventive Care and Screening: Inquiry Regarding Tobacco Use

Description: Percentage of patients aged 18 years and older who were queried about tobacco use one or more times within 24 months.

This measure is reported together with an office visit (as opposed to an inpatient E/M) only:

• 99201, 99202, 99203, 99204, 99205 (office — new patient),
• 99212, 99213, 99214, 99215 (office — established patient)

The claim must also contain the appropriate numerator, i.e., quality codes from the following set:

3. Measure #142, Preventive Care and Screening: Unhealthy Alcohol Use — Screening

Description: Percentage of patients aged 18 years and older who were screened for unhealthy alcohol use using a systematic screening method within 24 months

Pain physicians will report this measure with an office visit:

• 99201, 99202, 99203, 99204, 99205 (office — new patient),
• 99212, 99213, 99214, 99215 (office — established patient)

Whether or not the screening was performed should be reported with quality code 3016F, with a modifier if applicable:

• CPT II 3016F: Patient screened for unhealthy alcohol use using a systematic screening method
• CPT II 3016F–1P: Documentation of medical reason(s) for not screening for unhealthy alcohol use
• CPT II 3016F–8P: Unhealthy alcohol use screening not performed, reason not otherwise specified

Again, if your practice is limited to chronic pain medicine and you do not perform surgical anesthesia cases, you may choose to participate in the PQRI by reporting a quality measure on at least 80% of your Medicare claims. None of the three measures listed above is mandatory, but they are probably among the measures that will be the simplest for office-based pain physicians to incorporate into their practices.

There are other measures that are potentially equally suited to your practice including Measure #109 – Osteoarthritis (OA): Function and Pain Assessment and Measure 142 – Osteoarthritis (OA): Assessment for Use of Anti-inflammatory or Analgesic OTC Medications (Use of anti-inflammatory medications. To help you determine whether to report these or any other of the 153 PQRI measures, we refer you to the extremely practical worksheets and descriptions prepared by the American Medical Association and available at http://www.ama-assn.org/ama/pub/category/20358.html.

Alternative Method for Reporting: “Measure Groups”

In 2009, some physicians may participate in the PQRI by reporting on one or more sets of “Measure Groups,” which basically define subsets of patients for whom a more comprehensive set of quality interventions must be reported in order to qualify for the bonus. There are six measure groups, for six different conditions. One of these six conditions is of potential interest to pain practices: the back pain group, for which all four of the following measures would be reported:

1. Measure 148 – Back Pain: Initial Visit
2. Measure 149 – Back Pain: Physical Exam
3. Measure 150 – Back Pain: Advice for Normal Activities
4. Measure 151 – Back Pain: Advice Against Bed Rest

This group of measures would be reported for all patients aged 18 through 79 years of age with a diagnosis of back pain (per ICD-9-CM code) receiving office or other outpatient services, or undergoing back surgery. The physician could opt for either the “consecutive patient sample method” and report on all four measures for a minimum of 30 consecutive Medicare patients who meet the sample criteria, or the “80% patient sample method,” which would require reporting on at least 80% of the Medicare patients who meet the sample criteria during the applicable time period.

The AMA has also posted detailed instructions for reporting the measure groups on its website at http://www.ama-assn.org/ama/pub/category/20359.html. There is still more material, including FAQs , Measure Specifications and White Papers at http://www.cms.hhs.gov/pqri. All of the information in this Alert is of necessity introductory, and not a complete how-to manual. It is our hope that we have shown you that (1) if you successfully report the PQRI anesthesiology measures, you need do no more to earn your PQRI bonus and (2) if you do not perform any surgical anesthesia cases, there are other measures among which you may choose the best ones for you to report and thus earn the bonus. ABC clients with questions about the PQRI should contact their account managers. If you are not currently an ABC client, please send any questions to info@anesthesiallc.com.