Coding and Billing for Infectious Disease Quality Measures

A new physician quality reporting initiative (PQRI) is being implemented across the US, and, if done successfully, will provide physicians with a 2% bonus for their participation. Created by Congress in March 2007, the PQRI seeks to establish a financial incentive for eligible healthcare professionals to participate in a voluntary quality reporting program. However, this is not an opt-in program; eligible physicians will be penalized for not participating. "This is a bonus all or nothing system," said Hugh Gunner Deery, MD, FIDSA, Northern Michigan Infectious Diseases, Northern Michigan Regional Hospital, who led a workshop on the program during the 48th annual meeting of the IDSA in Vancouver.

"There's no payment for doing some of the work," he explained. "The position of the IDSA is ‘why not participate,’ given that you're going to be forced to do so, and soon there will be penalties for not participating," he said.

"The basic concept is to select measures that are important to your practice and patients, and to establish processes to systematically report the quality measures for each eligible patient," Deery said. "One of the challenges we have in infectious diseases is that of the 175 measures, there are very few that apply to us." In fact, there are 31 measures of the 175 that apply to infectious diseases. Some of the measures have an age, gender, or frequency limitation, such as patients with chronic illness for whom a particular process of care is provided only periodically.

The reporting is done mainly by including a quality code on a claim or through registries. "Having worked through each of the reporting methods, I think the take-home message for us will be that reporting through the registries is the way to go," Deery said.

Registry-based reporting allows third-party databases to collect and submit PQRI data to CMS. Many of the existing clinical registries are speciality or site-specific. Providers do not need to select CPT II codes, since the registry performs the measure calculations and performance data is submitted separately from the billing process. This is a fee-based service. In 2008, 32 registries successfully completed the CMS vetting process. Of note, HIV/AIDS Measures (159-162) and Hepatitis C #83 are only reportable through a registry.

Deery emphasized the importance of ensuring that the practice's billing software and clearinghouse can capture all the codes and associated modifiers used in PQRI for the measures you've selected. It is also important to discuss the reporting principles with staff, and develop a process for concurrent data collection so that eligible claims and PQRI codes are correctly identified and submitted. "Choose your measures wisely," Deery said. "Pick ones you do anyway and that are not tightly linked to patient adherence." He also advised practices to “bounce-proof” the billing service by making sure the billing service's practices are PQRI-compatible.

A list of measures for infectious diseases is available at the IDSA website, with links to each measure’s specifications.