pqri measure coding and reporting principles - Indiana Academy of ...

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_____ _____ _____ _____ Documentation of system reason(s) for not prescribing an inhaled bronchodilator and spirometry test results demonstrate FEV 1 /FVC < 70% with COPD symptoms (e.g., dyspnea, cough/sputum, wheezing) (4025F-3P and 3025F) Spirometry results demonstrate FEV 1 /FVC ≥ 70% or patient does not have COPD symptoms (3027F) Spirometry test not performed or documented (3025F-8P) Inhaled bronchodilator not prescribed, reason not specified and spirometry test results demonstrate FEV 1 /FVC < 70% with COPD symptoms (e.g., dyspnea, cough/sputum, wheezing) (4025F-8P and 3025F) 53) Asthma: Pharmacologic Therapy - Percentage of patients aged 5 to 40 years with a diagnosis of mild, moderate, or severe persistent asthma who were prescribed either the preferred long-term control medication (inhaled corticosteroid) or an acceptable alternative treatment - This measure is to be reported a minimum of once per reporting period for all asthma patients seen during the reporting period. It is anticipated that clinicians who provide primary care services for the patient will submit this measure. ICD-9: 493.00-493.02, 493.10-493.12, 493.20-493.22, 493.81, 493.82, 493.90, 493.92 and CPT: 99201-99215 (office/outpatient visit), 99241- 99245 (office/outpatient consult), 99383-99386, 99393-99396 (preventive), 99401-99404 (preventive counseling) Definition: acceptable alternative treatment (leukotriene modifiers, cromolyn sodium, nedocromil sodium, or sustained-released methylxanthines) _____ _____ _____ _____ Persistent asthma (mild, moderate, or severe) and preferred long term control medication or acceptable alternative treatment prescribed (4015F and 1038F) Persistent asthma (mild, moderate, or severe) and preferred long-term control medication or acceptable alternative treatment not prescribed for patient reasons (4015F-2P and 1038F) Intermittent asthma (1039F) Persistent asthma (mild, moderate, or severe) and preferred long-term control medication or acceptable alternative treatment not prescribed, reason not specified (4015F-8P and 1038F) 60) Gastroesophageal Reflux Disease (GERD): Assessment for Alarm Symptoms - Percentage of patients aged 18 years and older with a diagnosis of GERD, seen for an initial evaluation, who were assessed for the presence or absence of the following alarm symptoms: involuntary weight loss, dysphagia, and GI bleeding - This measure is to be reported once for all GERD patients seen during the reporting period. Patients seen for an initial evaluation of GERD should have documentation in the medical record of the presence or absence of alarm symptoms. If the initial evaluation of GERD occurred prior to the reporting period, report the proper CPT Category II code with modifier indicated in the numerator coding indicating this is not the initial evaluation. It is anticipated that clinicians who provide care for patients with GERD will submit this measure. ICD-9: 530.81, 530.10-530.12, 530.19 and CPT: 99201-99215 (office/outpatient visit), 99241-99245 (office/outpatient consult) Definition: Patients assessed for the presence or absence of the following alarm symptoms: involuntary weight loss, dysphagia, and GI bleeding _____ _____ _____ _____ _____ Alarm symptoms assessed; none present (1070F) Alarm symptoms assessed; one or more present (1071F) Patient does not meet denominator inclusion because the initial evaluation of GERD occurred prior to the reporting period (1070F-8P) Alarm symptoms not assessed for medical reasons (1070F-1P) Alarm symptoms not assessed, reason not specified (1071F-8P) (Joy’s Comment: For successful reporting of this measure, physicians will have to report on this measure at least one time for every Medicare patient with GERD.) 61) Gastroesophageal Reflux Disease (GERD): Upper Endoscopy for Patients with Alarm Symptoms - Percentage of patients aged 18 years and older with a diagnosis of GERD, seen for an initial evaluation, with at least one alarm symptom who were either referred for upper endoscopy or had an upper endoscopy performed - This measure is to be reported once for all GERD patients seen during the reporting period. Patients seen for an initial evaluation of GERD and at least one alarm symptom will be referred for upper endoscopy or have an upper endoscopy performed. If the initial evaluation of GERD occurred prior to the reporting period, 5-12 *All CPT Codes, Descriptions, and Two-Digit Modifiers Only Are Copyright 2006 American Medical Association. GEN 2007 REV 07-01 Copyright 2007 Newby Consulting, Inc.
eport the proper CPT II Category II code with modifier indicated in the numerator coding indicating this is not the initial evaluation. It is anticipated that clinicians who provide care for patients with GERD will submit this measure. ICD-9: 530.81, 530.10-530.12, 530.19 and CPT: 99201-99215 (office/outpatient visit), 99241-99245 (office/outpatient consult) Definition: Alarm symptoms for GERD include involuntary weight loss, dysphagia, and GI bleeding. _____ Upper gastrointestinal endoscopy performed (3130F) _____ Documentation of referral for upper gastrointestinal endoscopy (3132F and 1071F) _____ Patient does not have alarm symptoms (1070F) _____ Initial evaluation of GERD occurred prior to the reporting period (1071F-8P) _____ Upper endoscopy not performed or patient not referred for upper endoscopy for medical reasons (e.g., patient has already had the procedure) (3130F-1P and 1071F) _____ Upper endoscopy not performed or patient not referred for upper endoscopy for patient reasons (3130F-2P and 1071F) _____ Upper endoscopy not performed or patient not referred for upper endoscopy for system reasons (3130F-3P and 1071F) _____ Upper endoscopy not performed or patient not referred for upper endoscopy, reason not specified (3130F- 8P and 1071F) (Joy’s Comment: For successful reporting of this measure, physicians will have to report on this measure and measure #60 at least one time for every Medicare patient with GERD.) 63) Gastroesophageal Reflux Disease (GERD): Barium Swallow- Inappropriate Use - Percentage of patients aged 18 years and older with a diagnosis of GERD, seen for an initial evaluation, who did not have a Barium swallow test ordered - This measure is to be reported once for all GERD patients seen during the reporting period. Patients being seen for an initial evaluation of GERD should not receive a barium swallow test. If the initial evaluation of GERD occurred prior to the reporting period, report the proper CPT Category II with modifier indicated in the numerator coding indicating this is not the initial evaluation. It is anticipated that clinicians who provide care for patients with GERD will submit this measure. ICD-9: 530.81, 530.10-530.12, 530.19 and CPT: 99201-99215 (office/outpatient visit), 99241-99245 (office/outpatient consult) Definitions: This is an overuse measure. For performance, the numerator will be calculated as the difference between patients in the denominator and patients for whom a CPT Category II code was reported for barium swallow test ordered. A higher score indicates appropriate treatment of patients with GERD (i.e., the proportion for whom a barium swallow test was not ordered). _____ _____ _____ _____ Barium swallow test ordered (3142F) Patient does not meet denominator inclusion because the initial evaluation of GERD occurred prior to the reporting period (3200F-8P) Barium swallow test ordered for medical reasons (3142F-1P) Barium swallow test not ordered (3200F) (Joy’s Comment: For successful reporting of this measure, physicians will have to report on this measure and measure #60 at least one time for every Medicare patient with GERD.) 64) Asthma Assessment - Percentage of patients aged 5 to 40 years with a diagnosis of asthma who were evaluated during at least one office visit within 12 months for the frequency (numeric) of daytime and nocturnal asthma symptoms - This measure is to be reported a minimum of once per reporting period for patients seen during the reporting period. It is anticipated that clinicians who provide primary care services for the patient with a diagnosis of asthma will submit this measure. ICD-9: 493.00-493.02, 493.10-493.12, 493.20-493.22, 493.81, 493.82, 493.90, 493.92 and CPT: 99201-99215 (office/outpatient visit), 99241- 99245 (office/outpatient consult), 99383-99386, 99393-99396 (preventive), 99401-99404 (preventive counseling) Definitions: To be counted in calculations of this measure, symptom frequency must be numerically quantified. Measure may also be met by clinician documentation or patient completion of an asthma assessment 5-13 *All CPT Codes, Descriptions, and Two-Digit Modifiers Only Are Copyright 2006 American Medical Association. GEN 2007 REV 07-01 Copyright 2007 Newby Consulting, Inc.
Page 1 and 2: PQRI MEASURE CODING AND REPORTING P
Page 3 and 4: ! The line item charge should be $0
Page 5 and 6: ICD-9: 250.00-250.93, 648.00-648.04
Page 7 and 8: _____ _____ _____ _____ _____ Beta-
Page 9 and 10: Definition: Pharmacologic Therapy:
Page 11: Definition: Characterization includ
Page 15 and 16: • Physicians and qualified nonphy
Page 17 and 18: preoperative medical evaluation (if
Page 19 and 20: The excision of malignant lesion co
Page 21 and 22: complex repairs (CPT codes 13100-13
Page 23 and 24: HEMORRHOIDECTOMY BY SIMPLE LIGATURE
Page 25 and 26: Medicare “Incident to Clarificati
Page 27 and 28: service or other face-to-face servi
Page 29 and 30: HOSPITAL OBSERVATION SERVICES - CPT
Page 31 and 32: If the physicians are each responsi
Page 33 and 34: documented. If the time is not docu
Page 35 and 36: Follow-Up Consultation Service Effe
Page 37 and 38: A physician (primary care or specia
Page 39 and 40: typical severity of the problem(s)
Page 41 and 42: Medicare Part B payment policy does
Page 43 and 44: HOME SERVICES - CPT CODES 99341-993
Page 45 and 46: the medical records must clearly do

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