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CMS Releases Revised Set of Measures for Physician Voluntary Reporting Program

*Last Updated in 2006*

The Centers for Medicare and Medicaid Services' (CMS') Physician Voluntary Reporting Program (PVRP) - which gives physicians a trial run with quality reporting began on January 1, 2006. Participating physicians have the option of sending CMS information about the quality of care they provide to Medicare beneficiaries. In return, CMS will provide them with confidential feedback on their performance, starting this summer.

The new demonstration program employs a set of quality measures, selected by CMS, against which the agency will evaluate patient care. Physicians will use temporary Healthcare Common Procedure Coding System (HCPCS) codes known as "G-codes" on existing claims forms to report whether they complied with the quality measures.

Late last month, CMS announced that it would be using a smaller set of measures for the program than previously planned. Originally, CMS proposed using 36 evidence-based quality measures. Subsequent feedback from the physician community on ways to improve the program, however, led CMS to switch to a smaller, core "starter set" of 16 measures "to lessen the potential reporting burden for physicians and better align the PVRP with other quality measurement activities affecting physicians." Of the 16 core measures, "assessment of elderly patients for falls" is the most applicable to AGS members and reflects AGS recommendations. For more background and the comprehensive list of measures, visit: http://www.americangeriatrics.org/2006PVRPstarter_set.pdf.

The measures included in the new "starter set" are either endorsed by the National Quality Forum (NQF) or in the NQF approval process -- except for the falls measure. AGS is working to get NQF approval of this and other geriatric measures and intends to continue working with CMS to expand the geriatric measures included in the PVRP. For more information on the PVRP, visit http://www.cms.hhs.gov/PhysicianFocusedQualInits/.

Q. Why is the Physician Voluntary Reporting Program (PVRP) being introduced by CMS at this juncture?

A. CMS is introducing the PVRP in early 2006 as a way to test their existing information systems and data analysis capabilities. This will give the Agency important information on how the system is currently working and how it might be improved in the future. It is also a good way to ascertain physicians' interest and ability to participate in the program. There has long been a sense that performance in healthcare needs to improve in the face of growing costs and literature demonstrating opportunity. Congress and others seek to foster improvement through performance based purchasing.

Q. What is CMS seeking to measure?

A. CMS is looking for data on both process and outcomes measures. The AGS position on pay for performance argues that structure, process and clinical outcomes measures used must be valid and relevant for the unique care needs of frail or vulnerable older adults. These measures should be evidence-based, clinically relevant, have clear association with improved outcomes of care, and be applicable to all patients whose care they assess.

Q. How should physicians report quality data in the PVRP?

A. Physicians will be able to submit their quality data thru the existing claims process. CMS has the G codes set up so that when physicians submit their claims, they can also indicate their activity related to a specific measure(s). Two types of codes are under consideration to serve the purpose of quality reporting: CPT II codes and G codes. (Category II codes are a relatively new coding mechanism developed by the AMA CPT Editorial Panel to allow for electronic reporting of quality measures by physicians. G codes were developed for the same purpose by the CMS.) At present, CMS is using the G codes only. CMS has designed the system so that every item of information needed for any measure is captured on the single claim form submitted.

Q. How will the new quality codes work?

A. For each measure, CMS gives providers several options among G codes. For many measures, there are three to four possibilities: One code would be used to indicate that the patient was eligible for and is receiving a certain therapy. Another G code would be used to indicate that the patient is eligible but not undergoing a certain therapy. The remaining G code would be used to indicate that the patient was not an eligible candidate for the therapeutic choices.

For some measures, there might be a fourth G code to allow physicians to indicate that a patient has not been under his or her treatment for a sufficient amount of time. Measures are reported in association with certain types of encounters. Here's an example for the "falls" measure, with instructions from CMS:

CMS Measure: Assessment of elderly patients for falls

Numerator:

G8055: Patient documented for the assessment for falls within last 12 months

G8054: Patient not documented for the assessment for falls within last 12 months

G8056: Clinician documented that patient was not an eligible candidate for the falls assessment measure within the last 12 months

Denominator: Patients 75 years of age or older:

E&M visit: 99201-99205, 99211-99215 (E&M); 99241-99245 (office consult); 99341-99350 (home visit); 99304-99306, 99307-99310 (nursing facility); G0344

And

Patients 75 years of age or older

Instructions: This measure is reported using the appropriate quality G-code indicator whenever the listed CPT services are provided to geriatric patients. This indicator, as well as other indicators related to assessments, should be provided only on an annual basis. It is anticipated that the clinical assessment would include annual review of the patient's fall history as part of a medically necessary visit.

Note: To understand this measure, recognize that CMS asks you to report annually that when a patient who is 75 years or older is seen for an office, home or nursing facility visit, you will also report on your claim form whether you did or did not document a falls assessment. A falls assessment is defined as, at the very least, a falls history and "documented" means that it is in your records, even if you did not necessarily perform the falls assessment yourself. Possible reasons rendering a patient ineligible are less obvious, but seeing a patient who is bed-bound or terminally ill at home or in a facility may complicate matters.

At this same visit, if the patient were diabetic, you might also report Hemoglobin A1c control. For a look at the starter set and full set of instructions click here.

Q. How should health care systems begin to participate in this program?

A. Health care practices can begin to participate in the PVRP immediately through the claims submission process. However, in order to do so, practice management systems need to adjust their systems to accept codes for the measures they plan to track. Paper encounter forms or electronic health records need to be updated as well. Practices might also want to develop a reference tool to enable physicians to select the correct code for the measure(s) being reported, i.e. a cheat sheet with the measures that apply to your setting and patients.

Pros/cons of participating in the PVRP

Q. What are reasons to participate?

A. Geriatricians have long felt that the fee-for-service payment mechanisms in place do not appropriately recognize the work and quality care we provide our patients. We are confident that the care we provide is of high quality, but to demonstrate this there needs to be a measurement process. This trial voluntary process is a start. The process is in its infancy and flaws are readily evident. However, participation in the process will provide lessons to all, while AGS works on the national level to improve the process and to insure that it is fair, valid and practical. These same measures may be used for payment in the future. Many private payers are utilizing pay-for-performance measures. Even specialty boards may use such measures as part of the maintenance of certification processes. Gaining knowledge and experience in performance measurement is important for all physicians. Finally, this measurement process may help all of us to continuously improve the care we provide.

Q. What are reasons not to participate?

A. There is no payment for your time and effort in adapting your practice administrative processes to report. If and when payment is associated with such a process, the measures may change. Some people object fundamentally to the concept of pay for performance or feel the specific measures are invalid. AGS recognizes these concerns and seeks to work with CMS and others to address them while moving quality measurement to a point where its promise can be achieved.