Coding and Compliance: Ace the Urology-Specific Quality Measures


It's important to remember that services paid under any other fee schedule is not included in the PQRS reporting. And this would include the Federally qualified health centers: Ambulance providers, Independent laboratories, Rural health care and supplies of durable medical equipment (DME). Go through this informative article based on the medical coding training tips and guidance provided by our speaker in a healthcare event.

Reporting threshold: We are told that the CMS Medicare would like you to report on one to three reportable measures. They would really like you to report on three reportable measures. And if there are no more than three measures that apply and you are reporting on these measures, each measure must be reported in at least 80% of the eligible cases.

If you are reporting on less than three, continue to do that and you still can receive the bonus but you most likely will have to validate the quality measures that you are reporting as per PQRS Medicare guidelines. They may come in and investigate and review the quality of measures under three that you’re using.

Now, if you have four or more PQRS measures apply to your practice and you are reporting on four measures, at least three measures must be reported for at least 80% of the eligible patients. What about the analysis of accurate reporting? Well this is expected to be performed at the individual levels by CMS. Score keeping on the reported success rate will be by your NPI your National Provider Identifier numbers. And payments will be made by Tax Identifying Number.

CMS has validation plans. But in general, there will be very infrequent reviews except if you're only reporting less than three quality measures. But you must report in the form and manner that they want you too. And your quality of data may be reported and it will be reported to do physician on request. But reporting to the public at this time is really not known if they will eventually report these quality measures to the public.

Theoretical profitability: Let's say that we see 120 patients per week and half of those are Medicare. So we've seen 60 Medicare patients per week of which we are reporting on 40% or 24 Medicare patients in which we are reporting PQRS every week. And for 52 weeks, we will see in a year 1248 Medicare PQRS reporting patient for that year.

Now, if we bring in $6,142 per urologist and he had seen 1248 eligible patients, patients for which he has reported quality measures and they have been acceptable, that comes out to a little bit less than $5 payment for patients.

Our expert mentioned this in a health system conference that certainly isn't a very large figure of revenue bought for the work. But why should the urologist take part in this program? The urologist will receive hopefully confidential feedback reports to support the quality improvement that he's trying to make. He will earn a bonus incentive payment. And he will make an investment in the future of his/her practice. In other words, he will prepare for hopefully higher incentives over time. He will prepare for mandatory reporting. This reporting for PQRS quality measures at this time is mandatory. It's voluntary. We do not know if this will become a mandatory reporting. He will also prepare for what may be down the road, the payment for performance, the P4P. And it may prepare him for public reporting of his quality PQRS measures.

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