Wednesday, December 11, 2013

In era of health reform, retail clinics become part of the health care delivery system

By 
Sylvana Yalda, M.D., a family medicine physician at Henry Ford Medical Center-Troy and a MinuteClinic medical director
JOHN SOBCZAK
Sylvana Yalda, M.D., a family medicine physician at Henry Ford Medical Center-Troy and a MinuteClinic medical director, said nurse practitioners at the retail clinics are good at calling her if they have questions about patient care.
Fast facts about retail clinics
• 12 percent to 14 percent of all visits to emergency departments can be seen in retail or convenient-care clinics.

• Average treatment costs are lower at retail clinics ($60 per visit) than urgent clinics ($124), physician offices ($127) and emergency departments ($356).

• Services include acute care; immunizations; wellness and preventive services; chronic-disease care; school, camp and sports physicals; and minor office procedures.

• Quality is comparable to other medical locations. For example, retail clinics had 92.7 percent compliance with quality for children with pharyngitis (inflammation of the throat), compared with a HEDIS (Healthcare Effectiveness Data and Information Set) average of 74.7 percent.

• Patient satisfaction scores are 93 percent for convenience and 90 percent for quality.

Source: Convenient Care Association, Philadelphia
A contract between Detroit-based Henry Ford Health System and MinuteClinic, a division of CVS Caremark Corp., is one example of how retail clinics are becoming a larger part of the health care delivery system in Southeast Michigan to meet an expected increase in patient demand next year under the Affordable Care Act.

Under the contract, Henry Ford provides at least five physician medical directors to 14 CVS MinuteClinics in metro Detroit to oversee clinical operations and supervise nurse practitioners. CVS plans to add three or four more MinuteClinics here and more than 150 nationally next year.
Paul Szilagyi
Paul Szilagyi
"Our physicians serve as medical directors to meet with nurse practitioners at MinuteClinics on a regular basis to review quality," said Paul Szilagyi, Henry Ford's vice president of primary care and medical centers. "They are a phone call away if the nurse practitioner has a question about a patient."
MinuteClinic locations
Ann Arbor, Canton Township, Farmington Hills, Fraser, Grosse Pointe, Macomb Township, Milford, Northville, Rochester Hills, Shelby Township, Southfield, Walled Lake, Waterford Township, Wyandotte
The contract also allows patients of the Henry Ford Medical Group to use the MinuteClinics as if they were one of the 27 Henry Ford-owned medical centers and nine affiliated physician offices.

Two years ago, officials at Henry Ford Health System recognized they needed additional access points for patients and others seeking care from Henry Ford doctors.

"The only way to get into the Henry Ford Health System was through (hospital) emergency departments or our ambulatory care clinics," Szilagyi said. "We wanted to create more doors to enter the system."

Henry Ford considered creating retail clinics on its own, he said, but concluded it would be better to seek an established company.

Because Woonsocket, R.I.-based MinuteClinic already had contracts with more than two dozen other health systems and physician group practices, including the Cleveland Clinic — and evidence showed that MinuteClinic quality was high and medical malpractice incidents low — Henry Ford decided to join forces with the retail clinics.

"CVS had already made a commitment to Detroit, and we felt they had the same commitments to access, quality and connections (to primary care doctors) as we did," Szilagyi said.

Another bonus for Henry Ford patients, Szilagyi said, is that MinuteClinic offers expanded evening and weekend access to care and affordable primary care prices.

Sylvana Yalda, M.D., a family medicine doctor at Henry Ford Medical Center-Troy and a MinuteClinic medical director, said the delivery of care has been convenient and high-quality.

"The nurse practitioner sees the patient, and we do chart reviews," Yalda said. "They call me for consultations and a second opinion if they have questions about a patient.

"Nurse practitioners are very good at following (national clinical care) guidelines, but some situations require a doctor's point of view."

Since January 2012, when Yalda became a MinuteClinic medical director at the Waterford Township, Rochester Hills and Southfield CVS centers, some of her patients have been seen by nurse practitioners at MinuteClinics, she said.
Sylvana Yalda, M.D.
Sylvana Yalda, M.D.
Nurse practitioners fax patient encounter notes to primary care physicians, Yalda said.

"I have received quite a few," she said. "It is very helpful to know the care my patients have received."

To improve the sharing of patient records with primary care doctors, Henry Ford Health and MinuteClinic are working to link electronic medical record systems, Szilagyi said.

Next year, Henry Ford should have MinuteClinic fully integrated with the health system's Epic electronic medical records, Szilagyi said, which will provide visit tracing and opportunies to do chronic disease management.

Retail clinic, urgent care growth

Because of health insurance expansion and the need to offer lower primary care costs, the number of retail clinics is projected to double over the next five years in the U.S. to 3,000, said Tine Hansen-Turton, executive director of the Philadelphia-basedConvenient Care Association.

Hansen-Turton said the Affordable Care Act is stimulating growth because 40 percent to 50 percent of the people who use retail clinics don't have a primary care physician, and many are uninsured.

"We expect to increase services as people become insured and seek lower-cost options of retail clinics," Hansen-Turton said. Costs for comparable services at retail clinics are 40 percent lower than in physician offices and urgent care centers and 80 percent less than emergency departments, she said.

"People will be more cost-sensitive because they will have higher out-of-pocket costs before they hit their deductibles," she said.

Like retail clinics, urgent care centers — which provide higher levels of care than retail clinics but less than hospital emergency departments — are also growing in numbers in Southeast Michigan to accommodate expected demand, said Mohammed Arsiwala, M.D., president of the Lansing-based Urgent Care Association of Michigan.

Under the Affordable Care Act, over the next several years, nearly 900,000 uninsured people in Michigan are expected to either purchase private health insurance through healthcare.gov or qualify for Medicaid.

"We won't see much more growth in the next year," Arsiwala said. "But the second year, 2015, we will start to see growth" in patient volumes at urgent clinics, he said. It will take time for newly insured patients to learn how best to access the health care system.

One concern has been that the influx of newly covered patients will overload the primary care delivery system. Primary care physicians, hospitals and other providers have been ramping up care recently for the expected increase in volume.

Besides CVS, pharmacies including those inside Walgreen Co. and Rite Aid Corp. stores have started retail clinics in various ways to take advantage of national changes in health care that are projected to add 16 million privately insured patients and 16 million Medicaid beneficiaries starting in 2014.

In a 2-year-old pilot program that began in Detroit, Rite Aid has established virtual NowClinics in nine stores in Michigan. NowClinic uses computers and telemedicine to link customers with remotely based advanced-practice nurses and physicians.

"Our online clinics have computer kiosks adjacent to the pharmacy in a private room with a computer," said Ashley Flower, senior manager of public relations for Camp Hill, Pa.-based Rite Aid.

Flower said customers can talk with nurses for free, but a 10-minute consultation with a physician costs $45. Customers also can consult with medical providers using their home computer, she said.

While Deerfield, Ill-based Walgreen doesn't currently operate its Take Care retail clinics in Michigan, the nation's largest pharmacy chain operates more than 400 clinics in 21 states — including Illinois, Indiana, Ohio and Pennsylvania — as well as the District of Columbia, said Jim Cohn, a Walgreen spokesman.

The company also has contracted with 15 health systems to integrate its clinics with system hospitals. Those health systems include Baltimore-based Johns Hopkins Health System and Indianapolis-based Community Health Network.

Convenient, not comprehensive

Retail clinics are positioned to meet the needs of people who don't have a doctor or can't get a convenient appointment, Cohn said.

But Arsiwala of the Urgent Care Association of Michigan cautioned that retail clinics are limited in the types of care they can provide.

"Urgent care centers offer comprehensive medical care for people who need it urgently and cannot be seen by primary care doctors," said Arsiwala, who also is CEO of 10-center Michigan Urgent Care Centers.

"Pharmacy retail clinics are a very commercial side of the business," Arsiwala said. "They have nurse practitioners working for them. They don't have X-rays or comprehensive testing. They treat very minor complaints like earache or sore throats."
Nancy Gagliano, M.D.
Nancy Gagliano, M.D.
Nancy Gagliano, M.D., MinuteClinic's chief medical officer, said retail clinics can take on a large range of basic primary care services. Those include treating strep throat, bladder infections and pink eye and offering vaccinations for flu, pneumonia, pertussis and hepatitis.

Gagliano said patients do a good job deciding the appropriate care location for their medical issue.

"We send patients to ERs every once in a while," she said, "but working with health systems like Henry Ford helps us deliver the type of care that patients need. Doctors are seeing MinuteClinics as a place to augment primary care."

Gagliano said retail clinics stay within the boundaries of what nurse practitioners and physician assistants can do.

Yalda, the Henry Ford doctor and MinuteClinic medical director, said nurse practitioners at the clinics are well-trained in established clinical guidelines and refer more complicated patients to physicians or hospital emergency departments.

"If there is a sore throat and it is complicated, they will be referred," she said. "They know if a patient is not appropriate for the guidelines. They refer them right away. I get calls from them."

Although MinuteClinics lack the sophisticated diagnostic equipment found in hospitals and urgent care clinics, nurse practitioners can perform diabetic evaluations that include simple foot examinations to check for circulation problems or infections and can conduct blood sugar and blood pressure tests, Yalda said.

Gagliano said 50 percent of patients who come to a MinuteClinic do not have a primary care physician, and 50 percent of those patients visit during evening or weekend hours.

"Patients tell us if it weren't for us, they would go to an emergency department," Gagliano said. "We are reducing overall health care downstream costs."


mHealth Alliance Honors Mobile Health Visionaries in First-Ever Awards Ceremony at mHealth Summit


The mHealth Alliance, an organization dedicated to advancing the use of mobile technologies to improve health outcomes in low- and middle-income countries, announced this evening the winners of the Holly Ladd mHealth Pioneer Award and the mHealth Alliance Collaboration Award. This marks the first time that the Alliance has extended these honors. Dr. Richard Gakuba of Rwanda received the Holly Ladd mHealth Pioneer Award, while the Ananya partnership of Bihar, India, received the mHealth Alliance Collaboration Award. The awards were presented at a dinner celebrating the Alliance's fifth anniversary, which coincides with the fifth annual mHealth Summit, of which the Alliance is an organizing partner.
"These awards are designed to honor visionaries in the field of the mHealth - individuals and organizations whose work serves as a shining example of what is possible when we use mobile technologies strategically to improve health outcomes in developing countries," said Dr. Patricia Mechael, executive director of the mHealth Alliance. "We are delighted to have the opportunity to honor these outstanding members of the mHealth community, and we're grateful to the co-sponsors that have made it possible to recognize them."
The Holly Ladd mHealth Pioneer Award is co-sponsored by the mHealth Alliance, FHI 360 and the Rockefeller Foundation, and it includes a $5,000 cash prize and covers travel expenses to bring Dr. Gakuba to the mHealth Summit.
The Holly Ladd mHealth Pioneer Award
Dr. Richard Gakuba, the former national e-Health coordinator of Rwanda, received the Holly Ladd mHealth Pioneer Award - named in honor of Holly Ladd, a champion of community building and skills transfer in mHealth. The award recognizes an individual who is advancing sustainable solutions for personal and community health empowerment through the use of mobile technology.
"In just a few short years, the mHealth Alliance has been instrumental in making mHealth ubiquitous in global health. It demonstrates how philanthropic dollars, leveraged at the right moment, can catalyze entire fields," said Dr. Judith Rodin, President of The Rockefeller Foundation. "This progress has been further possible through visionary champions around the world like Dr. Richard Gakuba, who recognized the potential of mHealth and eHealth, and demonstrated how it can help transform health systems anywhere."
Dr. Gakuba was honored for his pioneering work, which has led to the creation and implementation of a national e-Health strategy for Rwanda. This strategy has created a regulatory environment that is enabling mHealth projects and programs to flourish and scale. Dr. Gakuba's work has helped to optimize the effectiveness of health care delivery and made health services more affordable in Rwanda.
"FHI 360 is honored to support the Holly Ladd mHealth Pioneer Award this year," said Albert J. Siemens, Ph.D., Chief Executive Officer of FHI 360. "The award acknowledges Holly's vision of how communication technology can transform the lives of millions of people around the globe. It celebrates her outstanding leadership and passion that have been an inspiration for so many."
Holly Ladd was the Director of SATELLIFE, which pioneered access to peer-reviewed medical and public health information for health care workers in developing communities via electronic-based information technology and low-earth orbit satellites. A true innovator in the development of systems to support health workers and strengthen health systems, Holly trusted the passion of health care workers to overcome a lack of familiarity with computers. When SATELLIFE joined FHI 360 in 2011, Holly redoubled her commitment to using mobile technology to expand knowledge, build human capacity and improve lives. The Holly Ladd mHealth Pioneer Award celebrates her innovation, compassion and magnanimity.

The mHealth Alliance Collaboration Award
The mHealth Alliance Collaboration Award was presented to the partners in the Ananya project, which is using mobile technologies in Bihar, India, to extend health information and services to families living beyond the reach of formal health facilities. The Collaboration Award recognizes individuals and/or organizations whose work through partnership has contributed significantly to advancing the field. The mHealth Alliance, itself, was created based on the vision that deepened collaboration and convening among members of the mHealth community could help overcome key obstacles in bringing effective mHealth products, projects, policies and programs to scale.
Ananya was honored for its ground-breaking model, including integrated approaches to achieving the Millennium Development Goals related to maternal and child health. The Government of Bihar (the Social Welfare Department and the Health Department), the Bill and Melinda Gates Foundation, BBC Media Action, CARE, Dimagi, the Grameen Foundation and World Health Partners will be recognized collectively for their innovative work that stands out as a leading example of an effective mHealth project operating at scale.
Note: Dr. Richard Gakuba will speak at mHealth+SocialGood, an event being held at the mHealth Summit on Tuesday, December 10th at 12 p.m. EST. This event will also be live streamed via www.mhealthsummit.org. Several members of the Ananya partnership will also be speaking at an mHealth Summit session held on Tuesday, December 10th at 5 p.m. EST. Both events will offer opportunities to hear directly from the award recipients and learn more about their work.

Tuesday, December 10, 2013

Florida Blue and Orlando Health Create Accountable Care Arrangement

JACKSONVILLE and ORLANDO, Fla., Dec. 10, 2013 /PRNewswire/ -- Florida Blue and Orlando Health Physician Partners announced today the execution of an accountable care agreement, which aims to improve the quality and efficiency of patient care in the Orlando area.
Through this arrangement, Orlando Health and Florida Blue plan to improve the individual patient experience, while also decreasing medical costs, by enhancing the coordination of care between the two organizations.
Starting on Jan. 1, 2014, the accountable care program will utilize a value-based compensation structure and serve as another example of Florida Blue's payment innovation efforts being deployed in the state. It will decrease medical costs and increase quality outcomes by rewarding the right combination of goals, including transparency, care coordination, consumer empowerment and lack of redundancy.
Orlando Health (OH) consists of approximately 500 employed physicians, both primary care and specialists, and eight hospitals in Lake, Seminole and Orange Counties. OH hospitals include Orlando Regional Medical Center, Dr. P. Phillips Hospital, South Seminole Hospital, South Lake Hospital, Health Central Hospital, Arnold Palmer Hospital for Children, Winnie Palmer Hospital for Women and Babies and MD Anderson Cancer Center.
"By coordinating efforts across the healthcare spectrum, we can deliver better outcomes for patients, provide for a more positive patient experience and improve management of medical costs," said Wayne Jenkins, M.D., President, Orlando Health Physician Partners. "We believe accountable care arrangements such as this are the future of the health care delivery system."
"Florida Blue is honored to partner with one of the leading health care organizations in the Orlando area to improve the quality of care for our members and their patients," said Pat Geraghty, chairman and CEO for Florida Blue. "Enlightened organizations like Orlando Health realize the importance of moving away from the fee-for-service model to one that seeks to eliminate the fragmentation of care, focuses on quality outcomes, and reduces the cost burden for all stakeholders."
About Orlando HealthOrlando Health is a $1.9 billion not-for-profit health care organization and a community-based network of physician practices, hospitals and care centers throughout Central Florida. Physician Associates, one of the largest multi-specialty practices in central Florida, consisting of more than 90 physicians in more than 20 locations, became a member of the Orlando Health family in January, 2013. The organization, which includes the area's only Level One Trauma Centers for adults and pediatrics, is a statutory teaching hospital system that offers both specialty and community hospitals.
About Florida BlueFlorida Blue, Florida's Blue Cross and Blue Shield company, is a leader in Florida's health care industry. Our mission is to help people and communities achieve better health. Florida Blue has approximately 4 million health care members and serves 15.5 million people in 16 states through its affiliated companies. Florida Blue is a not-for- profit, policyholder-owned, tax-paying mutual company. Headquartered in Jacksonville, Fla., it is an independent licensee of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield companies. 
For more information, visit www.FloridaBlue.com.

CMS updates Medicare manual to reflect Jimmo settlement


CMS updates Medicare manual to reflect Jimmo settlement
CMS updates Medicare manual to reflect Jimmo settlement
The Centers for Medicare & Medicaid Services has revised the Medicare Benefit Policy manual to clarify that skilled care and skilled therapy may be covered even for conditions that will not improve, per the settlement in the high-profile Jimmo v. Sebelius case.
The Jimmo plaintiffs argued that Medicare was improperly denying claims based on an “improvement standard.” Under this standard, beneficiaries would only receive Medicare coverage for skilled care that would improve their conditions.
In January, a federal judge granted final approval of a settlement in the case. Under the deal, CMS agreed to update the Medicare manual and take other steps to ensure that claims are not denied under the “improvement standard,” which the agency emphasizes never was a sanctioned policy. The manual revisions are intended to accomplish this goal.
For example, section 20.1.2-Determination of Coverage now states, “Coverage of skilled nursing care or therapy to perform a maintenance program does not turn on the presence or absence of a patient's potential for improvement from the nursing care or therapy, but rather on the patient's need for skilled care.”
Skilled care may be needed to maintain a current condition or prevent or slow a patient's deterioration, the manual now explains.
The revisions also enhance guidance on appropriate documentation for claims involving skilled care. Providers must substantiate that skilled care rather than non-skilled care was needed, in order to be reimbursed for so-called “maintenance therapy," according to an explanatory CMS Medicare Learning Network memo. Appropriate documentation is not "in and of itself" part of the definition of skilled care, but is the means by which contractors can determine whether skilled care is needed in a particular case, CMS noted. This is why the revisions include more specific guidance on this aspect of documentation. 
The manual revisions include specific examples of documenting skilled care. For instance, if a patient in a plaster cast has a circulatory condition that demands skilled care, the documentation should indicate the severity of the circulatory condition. Vague language such as “caregiver instructed in medication management” would not adequately support the need for skilled care, the manual notes.
Click here to access the revisions, released Friday.

Government Intervenes in False Claims Lawsuit Against Ipc the Hospitalist Co. Inc. Alleging Overbilling of Physician Services

Department of Justice
Office of Public Affairs
FOR IMMEDIATE RELEASE
Monday, December 9, 2013
Government Intervenes in False Claims Lawsuit Against Ipc the Hospitalist Co. Inc. Alleging Overbilling of Physician Services
The government has intervened in a lawsuit against IPC The Hospitalist Co. Inc., and its subsidiaries (IPC), alleging that IPC submitted false claims to federal health care programs, the Justice Department announced today.  IPC, based in North Hollywood, Calif., is one of the largest providers of hospitalist services in the United States, employing physicians and other health care providers who work in more than 1,300 facilities in 28 states.  Hospitalists are physicians who work only in hospitals and other long-term care facilities, overseeing and coordinating inpatient care from admission to discharge.
The lawsuit alleges that IPC physicians sought payment for higher and more expensive levels of medical service than were actually performed – a practice commonly referred to as “upcoding.”  Specifically, the lawsuit alleges that IPC encouraged its physicians to bill at the highest levels regardless of the level of service provided, trained physicians to use higher level codes and encouraged physicians with lower billing levels to “catch up” to their peers.
“We continue to be vigilant in our enforcement efforts to ensure that health care programs funded by the taxpayers pay only for appropriate costs,” said Assistant Attorney General for the Justice Department’s Civil Division Stuart F. Delery.
The lawsuit was filed by Dr. Bijan Oughatiyan, a former IPC physician, under the qui tam, or whistleblower, provisions of the False Claims Act, which permit private parties to sue for false claims on behalf of the government and to share in any recovery.  The Act also allows the government to intervene or take over the lawsuit, as it has done in this case, and to recover three times its damages plus civil penalties.  The government has asked the U.S. District Court in Chicago for 120 days to file its own complaint stating its allegations.

http://www.justice.gov/opa/pr/2013/December/13-civ-1294.html

Monday, December 9, 2013

Test Your Knowledge: Medicare Risk Adjustment (MRA) Online Assessment


Medicare Risk Adjustment (MRA) Assessment

In this climate of regulatory reform, our best defense is a great offense, and education is the only way to ensure compliance. 

This assessment covers general risk adjustment, documentation and HCC coding principles. 

If you are responsible for ensuring compliance among downstream entities, this tool will help you identify gaps and create meaningful education. 

If you work in the industry, I challenge you and anyone you work with to take this test.

The results, might suprise you...

To TAKE ASSESSMENT Click Here

For more information on ICD-10 contact ERM Consulting Inc. 

Friday, December 6, 2013

Medicare claims JFK Medical Center overbilled

A federal audit of JFK Medical Center in Atlantis found that it overbilled Medicare by $4.4 million.
The 460-bed hospital, part of HCA (NYSE: HCA), had its 2009 and 2010 Medicare billings reviewed by the U.S. Department of Health and Human Services’ Office of Inspector General (OIG), which released the report Wednesday. It recommended that the government attempt to recoup the money. The hospital is contesting the findings.
The auditors selected a $25.2 million portion of potentially erroneous claims out of $208 million in Medicare claims filed by the hospital for those years. Of that, 200 claims for $1.32 million were closely examined as a random sample.
While the OIG stated that JFK met Medicare billing requirements for the majority of its claims, it did not comply for 70 inpatient claims, totaling $293,869, out of the sample group that was examined. The most common error was billing claims as inpatient when they should have been considered outpatient observation stays, which have a lower reimbursement rate. In some cases, the wrong diagnosis groups were assigned to the claims.
The OIG extrapolated those findings to the $1.32 million sample size – assuming the same ratio of claims were overbilled – and declared that the hospital owes $4.4 million.
“Overpayments occurred primarily because the hospital did not have adequate controls to prevent incorrect billings of Medicare claims within the selected risk areas that contained errors,” the OIG stated in its study.
In its response, JFK said the government should be barred from recovering the alleged overpayments from 2009 because they are more than three years old, which is the deadline for such action. It also contested that 39 of those 70 inpatient claims were overbilled. In many of these cases, the patients’ physicians ordered that they be admitted to the hospital, and JFK simply followed their instructions, the hospital stated.
In addition, JFK said it’s not fair to extrapolate the alleged errors found to the larger group of claims to inflate the overbilling findings.
“Such extrapolation is erroneous as a matter of law, statistical integrity and fundamental fairness,” JFK stated in its official response to the OIG.
JFK added that it would strengthen its Medicare billing compliance.

Preparing for ICD-10, CMS goals for Small and Medium Sized Practices

This is a pretty good time to check and see if you’re on track for ICD-10 implementation. According to the Centers for Medicare and Medicaid Services (CMS), that means small- and medium-sized medical practices should have completed some goals.

Planning
These steps should be completed:
  • Identify resources
  • Create project team
  • Assess effects
  • Create project plan
  • Secure budget
Communications
Practices also should have:
  • Informed staff
  • Contacted vendors
  • Contacted payers
Medical practices need to stay in contact with their vendors and payers to track and monitor their ICD-10 progress. Hopefully contingency plans won't be needed.

Testing
Key personnel involved in ICD-10 testing should be trained. And CMS recommends testing the following elements for internal testing:
  • Database architecture
  • User interfaces
  • Algorithms based on diagnosis or institutional procedure codes
  • Code aggregation (grouping) models
  • Key metrics related to diagnosis or institutional procedure codes
  • All reporting logic based on diagnosis or institutional procedure codes
That should be completed so medical practices can begin external testing with healthcare payers, which should include:
  • Determine if the payer has educational programs and collaboration efforts to support providers through the transition
  • Use the high-dollar, high-volume, high-risk scenarios that your practice has created to produce test claims
  • Work with payers to develop test scenarios to conduct end-to-end testing, specifically identifying payment results
  • Communicate coding practices and scenarios to payers to build better relationships throughout the testing and transition process
  • Identify communication processes to identify and correct issues early with payers
  • Test information exchanges with hospitals to ensure appropriate handling.
  • Test healthcare information exchanges for critical operations to meet interoperability standards.
  • Test outsourced coding and billing operations with defined clinical scenarios to make sure these business operations continue as expected.
Local and national government entities may require reporting for a variety of purposes including:
  • Public health reporting
  • Quality and other metric reporting related to meaningful use
  • Medicare and Medicaid reporting and data exchange
  • Other mandated or contractually required exchange of information around services and patient conditions
The external testing should be going on through Oct. 1. Mostly because not all trading partners will be at the same level of preparedness.

Quick reference guide for PQRS measures, procedure codes and G-codes


Once an eligible patient and measure are identified, use this chart to select the appropriate procedure and G-code
By Government Relations staff
Formerly known as the Physician Quality Reporting Initiative (PQRI), the Physician Quality Reporting System is a voluntary reporting program that provides a financial incentive for certain health care professionals, including psychologists, who participate in Medicare to submit data on specified quality measures to the Centers for Medicare and Medicaid Services (CMS). In 2015, the reporting program will shift from an incentive program that offers bonuses for successful reporting to one in which penalties will be assessed for failure to participate.
Reporting in PQRS consists of selecting measures that match your Medicare population and identifying the types of services you provide to those patients. Medicare asks that you indicate whether or not the action described by the measures was taken through the use of a code (known as a “G” code) specific to each measure.
This chart provides a quick summary of Physician Quality Reporting System (PQRS) measures (in orange) and the procedure codes and G-codes available for each measure, based upon action taken. Prior to using this chart, providers will need to determine which measure is applicable by examining their Medicare patient population and identifying those who have a diagnosis covered by an eligible measure.
For more information on identifying eligible patients and measures, view the video on How to Report in the Physician Quality Reporting System. For additional materials and resources related to PQRS, visit the Quality Improvement Programs section at the APA Practice Organization’s Practice Central website.
Applicable procedure codes
Action taken
G-code (or F-code where applicable)

Measure #9: Major depressive disorder: antidepressant medication during acute phase for patients with MDD


90791, 90832,
90834, 90837, 
90845, 90849, 90853
Acute treatment with antidepressant medicationG8126: Patient with new episode of MDD documented as being treated with antidepressant medication during the entire 12 week acute treatment phase
Acute treatment with antidepressant medication not completed for documented reasonsG8128: Clinician documented that patient with a new episode of MDD was not an eligible candidate for antidepressant medication treatment or patient did not have a new episode of MDD
Acute treatment with antidepressant medication not completed, reason not givenG8127: Patient with new episode of MDD not documented as being treated with antidepressant medication during the entire 12 week acute treatment phase

#106: Major depressive disorder: diagnostic evaluation


90791, 90832,
90834, 90837, 
90845
DSM-IV-TR criteria for Major Depressive Disorder documented (One CPT II code & one G-code [1040F & G8930] are required on the claim form to submit this numerator option)
CPT II 1040F: DSM-IV-TR criteria for major depressive disorder documented at the initial evaluation 

and

G8930: Assessment of depression severity at the initial evaluation
DSM-IV-TR criteria for Major Depressive Disorder not documented, reason not otherwise specified (One CPT II code [1040-8P] or one G-code [G8931] are required on the claim form to submit this numerator option)
1040F with 8P: DSM-IV-TR criteria for major depressive disorder not documented at the initial evaluation, reason not otherwise specified

or 

G8931: Assessment of depression severity not documented, reason not given

#107: Major depressive disorder: suicide risk assessment


90791, 90832,
90834, 90837, 
90845
Suicide risk assessedG8932: Suicide risk assessed at the initial evaluation
Patient is not eligible for this measure because MDD is in remissionCPT II 3092F: Major depressive disorder, in remission
Suicide risk not assessed, reason not givenG8933: Suicide risk not assessed at the initial evaluation, reason not given

#128: Preventive care and screening: Body mass index screening and follow-up


90791, 90832,
90834, 90837
BMI calculated as normal, no follow-up plan requiredG8420: Calculated BMI within normal parameters and documented
BMI calculated above normal parameters, follow-up documentedG8417: Calculated BMI above normal parameters and a follow-up plan was documented
BMI calculated below normal parameters, follow-up documentedG8418: Calculated BMI below normal parameters and a follow-up plan was documented
BMI not calculated, patient not eligible/not appropriateG8422: Patient not eligible for BMI calculation
BMI calculated, patient not eligible/not appropriate for follow-up planG8938: BMI is calculated, but patient not eligible for follow-up plan
BMI not calculated, reason not givenG8421: BMI not calculated
BMI calculated outside normal parameters, follow-up plan not documented, reason not givenG8419: Calculated BMI outside normal parameters, no follow-up plan documented

#130: Documentation and verification of current medications in the medical record


90791, 90832,
90834, 90837,
90839, 96116,
96150, 96152
Current medications documentedG8427: Eligible professional attests to documenting the patient’s current medications to the best of his/her knowledge and ability
Current medications not documented, patient not eligibleG8430: Eligible professional attests the patient is not eligible for medication documentation
Current medications with name, dosage, frequency, route not documented, reason not givenG8428: Current medications not documented by the eligible professional, reason not given

#131: Pain assessment prior to initiation of patient therapy and follow-up


90791, 96116, 96150Pain assessment documented as positiveG8730: Pain assessment documented as positive utilizing a standardized tool and a follow-up plan is documented
Pain assessment documented as negative, no follow-up plan requiredG8731: Pain assessment documented as negative, no follow-up plan required
Patient not eligible for pain assessment for documented reasonsG8442: Documentation that patient is not eligible for a pain assessment
Pain assessment documented, follow-up plan not documented, patient not eligible/appropriateG8939: Pain assessment documented, follow-up plan not documented, patient not eligible/appropriate
Pain assessment not documented, reason not givenG8732: No documentation of pain assessment, reason not given
Pain assessment documented as positive, follow-up plan not documented, reason not givenG8509: Documentation of positive pain assessment; no documentation of a follow-up plan, reason not given

#134: Screening for clinical depression and follow-up plan


90791, 90832,
90834, 90837, 96150, 96151
Positive screen for clinical depression documented, follow-up plan documentedG8431: Positive screen for clinical depression with a documented follow-up plan
Negative screen for clinical depression documented, follow-up plan not requiredG8510: Negative screen for clinical depression, follow-up not required
Screening for clinical depression not documented, patient not eligible/appropriateG8433: Screening for clinical depression not documented, patient not eligible/appropriate
Screening for clinical depression documented, follow-up plan not documented, patient not eligible/appropriateG8940: Screening for clinical depression documented, follow-up plan not documented, patient not eligible/appropriate
Screening for clinical depression not documented, reason not givenG8432: Clinical depression screening notdocumented, reason not given

#173: Preventive care and screening: Unhealthy alcohol use—screening


90791, 90832,
90834, 90837, 
90845, 96150, 96152
Patient screened for unhealthy alcohol use using a systematic screening methodCPT II 3016F
Unhealthy alcohol use screening not performed, for medical reasons3016F with 1P: Documentation of medical reason(s) for not screening for unhealthy alcohol use (eg, limited life expectancy, other medical reasons)
Unhealthy alcohol use screening not performed, reason not otherwise specified3016F with 8P: Unhealthy alcohol use screening not performed, reason not otherwise specified

#181: Elder maltreatment screen and follow-up plan


90791, 96116,
96150
Elder maltreatment screen documented as positive and follow-up plan documentedG8733: Documentation of a positive elder maltreatment screen and documented follow-up plan at the time of the positive screen
Elder maltreatment screen documented as negative, follow-up plan not requiredG8734: Elder maltreatment screen documented as negative, no follow-up required
Elder maltreatment screen not documented, patient not eligibleG8535: No documentation of an elder maltreatment screen, patient not eligible
Elder maltreatment screen documented, patient not eligible for follow-upG8941: Elder Maltreatment Screen Documented, Patient not Eligible for Follow-Up
Elder maltreatment screen not documented, reason not givenG8536: No documentation of an elder maltreatment screen, reason not given
Elder maltreatment screen documented as positive, follow-up plan not documented, reason not givenG8735: No documentation of an elder maltreatment screen, patient not eligible

#226: Preventive care and screening: Tobacco use assessment and tobacco cessation intervention


90791, 90832,
90834, 90837, 
90845, 96150, 96151, 96152
Patient screened for tobacco useCPT II 4004F: Patient screened for tobacco use and received tobacco cessation intervention (counseling, pharmacotherapy, or both), if identified as a tobacco user
Patient screened for tobacco use and identified as a non-user of tobaccoCPT II 1036F: Current tobacco non-user
Tobacco screening not performed for medical reasons4004F with 1P: Documentation of medical reason(s) for not screening for tobacco use (eg, limited life expectancy, other medical reason)
Tobacco screening or tobacco cessation intervention not performed reason not otherwise specified4004F with 8P: Tobacco screening or tobacco cessation intervention not performed, reasonnot otherwise specified

#247: Substance use disorders – counseling


90791, 90832,
90834, 90837, 
90845, 96150, 96152
Patient counseled regarding psychosocial and pharmacologic treatment options for alcohol dependenceCPT II 4320F: Patient counseled regarding psychosocial and pharmacologic treatment options for alcohol dependence
Patient not counseled regarding psychosocial and pharmacologic treatment options for alcohol dependence, reason not otherwise specified4320F with 8P: Patient was not counseled regarding psychosocial and pharmacologic treatment options for alcohol dependence, reason not otherwise specified

#248: Substance use disorders Screening for depression


90791, 90832,
90834, 90837, 
90845, 96150, 96152
Patient screened for depressionCPT II 1220F: Patient screened for depression
Patient not screened for depression for medical reasons1220F with 1P: Documentation of medical reason(s) for not screening for depression
Patient not screened for depression, reason not otherwise specified1220F with 8P: Patient was not screened for depression, reason not otherwise specified

#325: Adult Major Depressive Disorder (MDD): Coordination of Care of Patients with Specific Comorbid Conditions – Note: Registry Reporting Only


90791, 90832, 90834, 90837, 
90845
Clinician treating Major Depressive Disorder communicates to clinician treating comorbid conditionG8959:Clinician treating MDD communicates to clinician treating comorbid condition
Clinician treating Major Depressive Disorder did not communicate to clinician treating comorbid condition, reason not givenG8960: Clinician treating MDD did not communicate to clinician treating comorbid condition, reason not given