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What is PQRI?
South Oakland Summarizes a New Medicare Reporting Initiative

June 22, 2007 - Many of our clients are asking about the new Provider Quality Reporting Initiative (PQRI), which the Center for Medicare and Medicaid Services (CMS) will launch on July 1, 2007. To help simplify things for everyone, we have provided this summary of the program and some things to think about as you consider whether or not to participate. If you do decide to participate, please let us know by June 29, 2007. If you have any questions after reading this summary, please do not hesitate to contact us.

First, we wish to assure all of our clients that, if they choose to participate, South Oakland Services will be able to report the data to CMS. The question to consider is whether the reward - an additional 1.5% of the total Medicare reimbursement - is worth the extra record-keeping on your part. Please review the following:

Overview

• This program will cover dates of service from July 1 through December 31, 2007.

• You must report on cases where Medicare is either primary or secondary carrier.

• Medicare will pay a 1.5% bonus of the total dollar amount of claims paid by Medicare during the submission period.

• Only one measure is clearly intended for anesthesiologists and CRNA’s, measure # 30:
  Surgical patients aged 18 years and older who have an order for a parenteral antibiotic to be given within one hour (if fluoroquinolone or vancomycin, two hours) prior to the surgical incision (or start of procedure when no incision is required) for whom administration of prophylactic antibiotic has been initiated within one hour (if fluroroquinolone or vancomycin, two hours) prior to the surgical incision (or start of procedure when no incision is required)

• You must report at least 80% of the cases in which the measure could have been performed and reported. CMS has provided a list of specific CPT codes to which this measure would apply. For those procedures, you must report if you have given the antibiotic, or if you have not given the antibiotic.

• There must be an order (most likely by the surgeon) for a parenteral antibiotic to be given (we do not necessarily need to see the order here at South Oakland).

• You will need to record the surgical incision time or surgery start time (this is different from your anesthesia start and stop time) and provide this information to us.

• Both the Anesthesiologist and the CRNA can report on the same patient.

• The bonus payment will be paid to the holder of the TIN under which the claims were submitted (group, provider or hospital).

• The payment will be limited to 1.5% of the total Medicare reimbursement for each provider in a group who qualifies for the bonus.

• The bonus payments will be sent out in mid-2008.

Things to Consider

• Can you identify your Medicare patients so that you will know if you must record the data? If not, you may need to report on all patients.

• How will you know which procedures CMS requires you to report on? We will supply you with a list. However, you will need to think about how you will keep the list easily available. You may consider simply reporting on all cases.

• How will you report this information to South Oakland Services? Some clients already have a place on the anesthesia record for “Antibiotic” and the time of the surgical incision. If not, we can supply an additional form that you will fill out along with the anesthesia record. This form will require patient name, medical record number, date of service, procedure, time of the surgical incision, name of the provider, whether the antibiotic was provided or not and, if provided, the name of the drug.

• Will the bonus be worth it? Take a hypothetical 10-anesthesiologist group providing 1,800 Medicare anesthetics from July – December. Assuming that the average number of units per case is 14, and that the 80-percent threshold is met, the group will receive a total bonus of approximately $6,119, paid next summer.

Please contact our office by June 29th if you wish to participate in the PQRI program.
 

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