Highlights of the proposed PQRI rules for 2010

New proposed PQRI rules for 2010 were published on July 1, 2009 on the Federal Registry. You can read the full rules here. CMS will accept comments on the Proposed Rule until August 31, 2009.

During the PQRI Registry Kick-Off Meeting some people complained that they haven't enough time to read the Federal Registry. I felt very patriotic after a nice July 4th display of fireworks in Vermont and decided to read the Federal Registry.



These are some of the highlights:

- "In addition, given our desire to transition from the use of the claims based reporting mechanism as the primary reporting mechanism for clinical quality measures for PQRI after 2010 to rely more heavily on registry-based reporting (see section II.G.2.d. of this proposed rule for further discussion), we do not believe it appropriate to add a new 6-month reporting period for claims-based reporting of individual measures.

- "Beginning with the 2010 PQRI, group practices who satisfactorily submit data on quality measures also would be eligible to earn an incentive payment equal to 2.0 percent of the estimated total allowed charges for all covered professional services furnished by the group practice during the applicable reporting period."

- "We propose that a “group practice” would consist of a physician group practice, as defined by a TIN, with at least 200 or more individual eligible professionals (or, as identified by NPIs) who have reassigned their billing rights to the TIN.

- "We note that the 6-month reporting period, beginning July 1, 2010, is proposed to be available for reporting on measures groups and for reporting using the registry-based reporting mechanism only.

- "If we finalize this proposal, then, unlike in prior years, an eligible professional would be able to earn a PQRI incentive payment through the EHR-based reporting mechanism in 2010."

- "Therefore, we propose to add an EHR-based reporting mechanism for the 2010 PQRI in
order to promote the adoption and use of EHRs and to provide both eligible professionals and CMS experience on EHR-based quality reporting."

- "In summary, we propose that for 2010, an eligible professional may choose to report data on PQRI quality measures through claims, to a qualified registry (for the qualification requirements for registries, see section II.G.2.i.(4) of this proposed rule), or through a qualified EHR product (for the qualification requirements for EHR vendors and their products, see section II.G.2.i.(5) of this proposed rule)."

- "While we propose to retain the claims-based reporting mechanism for 2010, we note that we are considering significantly limiting the claims-based mechanism of reporting clinical quality measures for the PQRI after 2010. This would be contingent upon there being an adequate number and variety of registries available and/or EHR reporting options."

- "Reducing our reliance on the claims-based reporting mechanism after 2010 will allow us and eligible professionals to devote available resources to maximizing
the potential of registries and EHRs for quality measurement reporting. Both mechanisms hold the promise of more sophisticated and timely reporting on clinical quality measures. Clinical data registries allow the collection of more detailed data, including outcomes, without the necessity of a single submission contemporaneously with claims billing, which overcomes some of the limitations of
the claims-based reporting mechanism. Registries can also provide feedback and quality improvement information based on reported data. Finally, clinical data registries can also receive data from EHRs, and therefore, serve as an alternative means to reporting clinical quality data extracted from an EHR. As we continue to qualify additional registries, we believe that there will be a sufficient number of qualified PQRI registries by 2011 to make it possible to reduce or even discontinue the claims-based reporting mechanism for most measures after 2010."

- "All claims for services furnished between January 1, 2010 and December 31, 2010 must be processed by no later than February 28, 2011 to be included in the 2010 PQRI analysis.

- "We propose the following new requirements for registries for the 2010
PQRI:
● Registries must have at least 25 participants;
● Registries must provide at least 1 feedback report
per year to participating eligible professionals;
● Registries must not be owned and managed by an
individual locally-owned single-specialty group (in other
words, single-specialty practices with only 1 practice
location or solo practitioner practices would be prohibited
from self-nominating to become a qualified PQRI registry);
● Registries must participate in ongoing 2010 PQRI
mandatory support conference calls hosted by CMS
(approximately 1 call per month);
● Registries must provide a flow and XML of a
measure’s calculation process for each measure type that
the registry intends to calculate; and
● Registries must use PQRI measure specifications to
calculate reporting or performance unless otherwise stated."

- "Regardless of the reporting mechanism chosen by the
eligible professional, we propose that the minimum patient
sample size for reporting individual quality measures be 15
Medicare Part B FFS patients for the 12-month reporting
period. An eligible professional would need to meet this
minimum patient sample size requirement for at least one
measure on which the eligible professional chooses to
report."

- "Unlike the 2009 PQRI, which required that eligible
professionals report on consecutive patients (that is,
patients seen in order, by date of service), the 30
patients on which an eligible professional would need to
report a measures group for 2010 would not need to be
consecutive patients."
- "In addition, the questions we receive from eligible
professionals indicate that many eligible professionals are
not clear on how to determine which patients are
“consecutive” and should be included in the patient sample.
We believe that any adverse effect on the reliability or
validity of the quality information received as a result of
the removal of the requirement to report on patients seen
consecutively and allowing eligible professionals to report
on any 30 patients would be minimal."

- "Group practices interested in participating in the 2010 PQRI through the group practice reporting option would be required to submit a self-nomination letter to CMS or a CMS designee requesting to participate in the 2010 PQRI group practice reporting option. We propose that each group practice would be required to meet the following requirements:
● Have an active Individuals Access to CMS Systems
(IACS) user account;
● Provide CMS or a CMS designee with the group
practice’s TIN and the NPI numbers and names of all
eligible professionals who will be participating as part of
the group practice (that is, all individual NPI numbers
CMS-1413-P 258
associated with the group practice’s TIN). This
information must be provided in an electronic format
specified by CMS, such as in an Excel spreadsheet; and
● Agree to have the group practice’s PQRI quality
measurement performance rates for each measure publicly
reported by posting of the results on a CMS Web site."

- "We propose that group practices
would be required to submit information on these measures
using a data collection tool based on the data collection
tool used in CMS’ Medicare Care Management Performance
(MCMP) demonstration and the quality measurement and
reporting methods used in CMS’ PGP demonstration. We
propose that physician groups selected to participate in
the 2010 PQRI through the group practice reporting option
would be required to report on a common set of 26
NQF-endorsed quality measures that are based on measures
currently used in the MCMP and/or PGP demonstration and
that target high-cost chronic conditions and preventive
care. These quality measures are identified in Table 34.
Additional information on the MCMP and PGP demonstrations
is posted on the Medicare Demonstrations section of the CMS
Web site at http://www.cms.hhs.gov/DemoProjectsEvalRpts/MD/list.asp#Top
OfPage

- "We propose a unique reporting mechanism for the group
practice reporting option that would not be available to
individual eligible professionals participating in the 2010
PQRI. We propose that each physician group selected to
participate in the group practice reporting option would
have access to a database (that is, a data collection tool)
that would include the assigned beneficiary sample and the
quality measures."

- "Identical to the sampling method used in the PGP demonstration, the random
sample must consist of at least 411 assigned beneficiaries."

- "We anticipate being able to provide the selected physician groups with access
to this prepopulated database by the fourth quarter of 2010. The physician group would be required to populate the remaining data fields necessary for capturing quality measure information on each of the assigned beneficiaries."

- "TABLE 34: Measures Proposed for Physician Groups
Participating in the 2010 PQRI Group Practice Reporting
Option"



- "For example, information on the measure development process
employed by us when CMS or a CMS contractor is the measure
developer is available in the “Measures Management System
Blueprint” found on the CMS Web site at
http://www.cms.hhs.gov/apps/QMIS/mmsBlueprint.asp.
Eligible professionals also have the opportunity to
provide input on a measure as the measure is being vetted
through the NQF consensus endorsement process (and
previously, the AQA consensus adoption process). In
particular, the NQF employs a public comment period for
measures vetted through its consensus endorsement process
(and previously, for the AQA, its consensus adoption
process).
Finally, eligible professionals have an opportunity to
provide input on the measures proposed for inclusion in the
2010 PQRI through this proposed rule, which provides a
60-day comment period."

- "Measures that are high impact and support CMS and
HHS priorities for improved quality and efficiency of care
for Medicare beneficiaries. These current and long term
priority topics include: prevention; chronic conditions;
high cost and high volume conditions; elimination of health
disparities; healthcare-associated infections and other
conditions; improved care coordination; improved
efficiency; improved patient and family experience of care;
improved end-of-life/palliative care; effective management
of acute and chronic episodes of care; reduced unwarranted
geographic variation in quality and efficiency; and
adoption and use of interoperable HIT."

- "TABLE 17: Proposed 2010 Measures Selected From the 2009
PQRI Quality Measure Set Available for Either Claims-based
Reporting or Registry-based Reporting"

1 - Diabetes Mellitus: Hemoglobin A1c Poor Control in Diabetes Mellitus.
2 - Diabetes Mellitus: Low Density Lipoprotein (LDL–C) Control in Diabetes Mellitus.
3 - Diabetes Mellitus: High Blood Pressure Control in Diabetes Mellitus.
6 - Coronary Artery Disease (CAD): Oral Antiplatelet Therapy Perscribed for Patients with CAD.
9 - Major Depressive Disorder (MDD): Antidepressant Medication During Acute Phase for Patients with MDD.
10 - Stroke and Stroke Rehabilitation: Computed Tomography (CT) or Magnetic Resonance Imaging (MRI) Reports.
12 - Primary Open Angle Glaucoma (POAG): Optic Nerve Evaluation.
14 - Age-Related macular Degeneration (AMD): Dilated Macular Examination.
18 - Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level of Severity of Retinopathy.
19 - Diabetic Retinopathy: Communication with the Physician Managing On-going Diabetes Care.
20 - Perioperative Care: Timing of Antibiotic Prophylaxis— Ordering Physician.
21 - Perioperative Care: Selection of ProphylacticAntibiotic—First OR Second Generation Cephalosporin.
22 - Perioperative Care: Discontinuation of Prophylactic Antibiotics (Non-Cardiac Procedures).
23 - Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients).
24 - Osteoporosis: Communication with the Physician Managing On-going Care Post Fracture.
28 - Aspirin at Arrival for Acute Myocardial Infarction (AMI).
30 - Perioperative Care: Timing of Prophylactic Antibiotics—Administering Physician.
31 - Stroke and Stroke Rehabilitation: Deep Vein Thrombosis Prophylaxis (DVT) for Ischemic Stroke or Intracranial Hemorrhage.
32 - Stroke and Stroke Rehabilitation: Discharged on Antiplatelet Therapy.
35 - Stroke and Stroke Rehabilitation: Screening for Dysphagia.
36 - Stroke and Stroke Rehabilitation: Consideration for Rehabilitation Services.
39 - Screening or Therapy for Osteoporosis for Women Aged 65 Years and Older.
40 - Osteoporosis: Management Following Fracture.
41 - Osteoporosis: Pharmacologic Therapy
43 - Coronary Artery Bypass Graft (CABG): Use of Internal Mammary Artery (IMA) in Patients with Isolated CABG Surgery.
44 - Coronary Artery Bypass Graft (CABG): Preoperative Beta-Blocker in Patients with Isolated CABG Surgery.
45 - Perioperative Care: Discontinuation of Prophylactic Antiobitics (Cardiac Procedures).
46 - Medication Reconciliation: Reconciliation After Discharge from an Inpatient Facility.
47 - Advance Care Plan
48 - Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 6 Years and Older.
49 - Urinary Incontinence: Characterization of Urinary Incontinence in Women Aged 65 Years and Older.
50 - Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older.
51 - Chronic Obstructive Pulmonary Disease (COPD): Spirometry Evaluation.
52 - Chronic Obstructive Pulmonary Disease (COPD): Bronchodilator Therapy.
53 - Asthma: Pharmacologic Therapy
54 - 12-Lead Electrocardiogram (ECG) Performed for Non-Traumatic Chest Pain.
55 - 12-Lead Electrocardiogram (ECG) Performed for Syncope.
56 - Community-Acquired Pneumonia (CAP): Vital Signs.
57 - Community-Acquired Pneumonia (CAP): Assessment of Oxygen Saturation.
58 - Community-Acquired Pneumonia (CAP): Assessment of Mental Status.
59 - Community-Acquired Pneumonia (CAP): Empiric Antibiotic.
64 - Asthma: Asthma Assessment
65 - Treatment for Children with Upper Respiratory Infection (URI): Avoidance of Inappropriate Use.
66 - Appropriate Testing for Children with Pharyngitis.
67 - Myelodysplastic Syndrome (MDS) and Acute Leukemias: Baseline Cytogenetic Testing Performed on Bone Marrow.
68 - Myelodysplastic Syndrome (MDS): Documentation of Iron Stores in Patients Receiving Erythropoietin Therapy.
69 - Multiple Myeloma: Treatment with Bisphosphonates.
70 - Chronic Lymphocytic Leukemia (CLL): Baseline Flow Cytometry.
71 - Breast Cancer: Hormonal Therapy for Stage IC–IIIC Estrogen Receptor/Progesterone Receptor (ER/PR) Positive Breast Cancer.
72 - Colon Cancer: Chemotherapy for Stage III Colon Cancer Patients.
76 - Prevention of Catheter-Related Bloodstream Infections (CRBSI): Central Venous Catheter (CVC) Insertion Protocol.
79 - End Stage Renal Disease (ESRD): Influenza Immunization with Patients in ESRD.
84 - Hepatitis C: Ribonucleic Acid (RNA) Testing Before Initiating Treatment.
85 - Hepatitis C: HCV Genotype Testing Prior to Treatment.
86 - Hepatitis C: Antiviral Treatment Prescribed
87 - Hepatitis C: HCV Ribonucleic Acid (RNA) Testing at Week 12 of Treatment.
89 - Hepatitis C: Counseling Regarding Risk of Alcohol Consumption.
90 - Hepatitis C: Counseling Regarding Use of Contraception Prior to Antiviral Therapy.
91 - Acute Otitis Externa (ACE): Topical Therapy
92 - Acute Otitis Externa (ACE): Pain Assessment.
93 - Acute Otitis Externa (ACE): Systemic Antimicrobial Therapy—Avoidance of Inappropriate Use.
99 - Breast Cancer Resection Pathology Reporting: pT Category (Primary Tumor) and pN Category (Regional Lymph Nodes) with Histologic Grade.
100 - Colorectal Cancer Resection Pathology Reporting: pT Category (Primary Tumor) and pN Category (Regional Lymph Nodes) with Histologic Grace.
102 - Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low-Risk Prostate Cancer Patients.
104 - Prostate Cancer: Adjuvant Hormonal Therapy for High-Risk Prostate Cancer Patients.
105 - Prostate Cancer: Three-Dimensional (3D) Radiotherapy.
106 - Major Depressive Disorder (MDD): Diagnostic Evaluation.
107 - Major Depressive Disorder (MDD): Suicide Risk Assesmment.
108 - Rheumatoid Arthritis (RA): Disease Modifying Anti-Rheumatic Drug (DMARD) Therapy.
109 - Osteoarthritis: Function and Pain Assessment.
110 - Preventive Care and Screening: Influenza Immunization for Patients =50 Years Old.
111 - Preventive Care and Screening: Pneumonia Vaccination for Patients 65 Years and Older.
112 - Preventive Care and Screening: Screening Mammography.
113 - Preventive Care and Screening: Colorectal Cancer Screening.
114 - Preventive Care and Screening: Inquiry Regarding Tobacco Use.
115 - Preventive Care and Screening: Advising Smokers to Quit.
116 - Antibiotic Treatment for Adults with AcutemBronchitis: Avoidance of Inappropriate Use.
117 - Diabetes Mellitus: Dilated Eye Exam in Diabetic Patient.
119 - Diabetes Mellitus: Urine Screening forMicroalbumin or Medical Attention for Nephropathy in Diabetic Patients.
121 - Chronic Kidney Disease (CKD): Laboratory Testing (Calcium, Phosphorous, Intact Parathyroid Hormone (iPTH) and Lipid Profile).
122 - Chronic Kidney Disease (CKD): Blood Pressure Management.
123 - Chronic Kidney Disease (CKD): Plan of Care—Elevated Hemoglobin for Patients Receiving Erythropoiesis-Stimulating Agents (ESA).
124 - Health Information Technology (HIT): Adoption/Use of Electronic Health Records (EHR).
126 - Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy—Neurological Evaluation.
127 - Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention—Evaluation of Footwear.
128 - Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up.
130 - Documentation and Verification of Current Medications in the Medical Record.
131 - Pain Assessment Prior to Initiation of Patient Therapy and Follow-Up.
134 - Screening for Clinical Depression and Follow-Up Plan.
135 - Chronic Kidney Disease (CKD): Influenza Immunization.
140 - Age-Related Macular Degeneration (AMD): Counseling on Antioxidant Supplement.
142 - Osteoarthritis (OA): Assessment for Use of Anti-Inflammatory or Analgesic Over-the-Counter (OTC) Medications.
145 - Radiology: Exposure Time Reported for Procedures Using Fluoroscopy.
146 - Radiology: Inappropriate Use of ‘‘Probably Benign’’ Assessment Category in Mammography Screening.
147 - Nuclear Medicine: Correlation with Existing Imaging Studies for All Patients Undergoing Bone Scintigraphy.
153 - Chronic Kidney Disease (CKD): Referral for Arteriovenous (AV) Fistula.
154 - Falls: Risk Assessment
155 - Falls: Plan of Care
156 - Oncology: Radiation Dose Limits to Normal Tissues.
157 - Thoracic Surgery: Recording of Clinical Stage for Lung Cancer and Esophageal Cancer Resection.
158 - Endarterectomy: Use of Patch During Conventional Endarterectomy.
163 - Diabetes Mellitus: Foot Exam
172 - Hemodialysis Vascular Access Decision-Making by Surgeon to Maximize Placement of Autogenous Arterial Venous (AV) Fistula.
173 - Preventive Care and Screening: Unhealthy Alcohol Use—Screening.
175 - Pediatric End Stage Renal Disease (ESRD): Influenza Immunization.
176 - Rheumatoid Arthritis (RA): Tuberculosis Screening.
177 - Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity.
178 - Rhuematoid Arthritis (RA): Functional Status Assessment.
179 - Rheumatoid Arthritis (RA): Assessment and Classification of Disease Prognosis.
180 - Rheumatoid Arthritis (RA): Glucocorticoid Management.
181 - Elder Maltreatment Screen and Follow-Up Plan.
182 - Functional Outcome Assessment in Chiropractic Care.
183 - Hepatitis C: Hepatitis A Vaccination in Patients with HCV.
184 - Hepatitis C: Hepatatis B Vaccination in Patients with HCV.
185 - Endoscopy & Polyp Surveillance: Colonoscopy Interval for Patients with a History of Adenomatous Polyps—Avoidance of Inappropriate Use.
186 - Wound Care: Use of Compression System in Patients with Venous Ulcers.

- "TABLE 20: Proposed 2010 Measures Available for EHR-based
Reporting"



- "The 6 new measures groups proposed for
the 2010 PQRI are:
(1) Coronary Artery Disease (CAD);
(2) Heart Failure (HF);
(3) Ischemic Vascular Disease (IVD);
(4) Hepatitis C;
(5) Human Immunodeficiency Virus (HIV)/Acquired Immune Deficiency Syndrome (AIDS);
(6)Community Acquired Pneumonia (CAP)."

- "In December 2008, we listed, by State, the names of eligible
professionals who participated in the 2007 PQRI on the
Physician and Other Health Care Professionals Directory."

- "Based on the assumptions discussed above, we estimate
the total annual cost per eligible professional associated
with claims-based reporting to range from $174.45 [($0.21
per measure X 3 measures X 15 cases per measure) + $165] to
$617.70 [($10.06 per measure X 3 measures X 15 cases per
measure) + $165]."

- "For registry-based reporting, eligible professionals
must generally incur a cost to submit data to registries.
Estimated fees for using a qualified registry range from a
nominal charge for an eligible professional to use the
registry to costing eligible professionals several thousand
dollars. Thus, we conservatively estimate the cost
incurred by an eligible professional to participate in PQRI
via registry-based reporting to be approximately $500 per
eligible professional.