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Measure of the month: coronary artery disease

By Lisa Kirkland, FACP

From the November ACP Hospitalist, copyright © 2008 by the American College of Physicians

Sidebar: Numerator CPT II Code Modifier

In accordance with a law passed by Congress late in 2006, physicians and other eligible professionals are able to receive bonus payments of 1.5% of their total allowed Medicare charges, subject to a cap, by submitting information for defined quality measures. Many of these measures were developed by the AMA-convened Physician Consortium for Performance Improvement®, in collaboration with the National Committee for Quality Assurance (NCQA) and/or a medical specialty society.

In July, CMS reported $36 million in bonus payments to many of the more than 56,700 health professionals who correctly reported quality information to Medicare under the 2007 Physician Quality Reporting Initiative (PQRI). The average incentive amount for individual professionals was over $600 and average incentive payment for a physician group practice was over $4,700, with the largest payment to a physician group practice totaling over $205,700.

Hospitalists have 11 quality measures available to them for the 2008 PQRI and can choose up to three measures per reporting period:

• ACE inhibitor, ARB in heart failure,
• antiplatelets in CAD,
• beta-blocker in CAD with prior MI,
• DVT prophylaxis in stroke,
• antiplatelets in stroke,
• anticoagulant in stroke with atrial fibrillation,
• tPA considered in stroke,
• dysphagia screen in stroke,
• rehab considered in stroke,
• advance care plan,
• VAP prevention (head elevation), and
• CRBSI prevention (CVC insertion protocol).

The current reporting period ends Dec. 31. The program will continue in 2009.

For a specific measure, the eligible (“denominator”) patient population is identified by both ICD-9 diagnosis codes and CPT evaluation/management (E/M) service codes. If a patient falls into that denominator population, the appropriate CPT-II code(s) and modifiers for the individual patient (“numerator”) are required for submission. A modifier is required if a patient is in the eligible population but does not receive the measure; the explanation must be documented in the chart as a medical, patient, system, or unspecified reason.

Dr. Kirkland is a hospitalist at the Mayo Clinic in Rochester, Minn., and a critical care specialist at Abbott Northwestern Hospital in Minneapolis. She is a member of ACP Hospitalist’s editorial advisory board.

Measure #7: Beta-blocker therapy for coronary artery disease patients with prior myocardial infarction

The frequency of this measure is a minimum of once per reporting period. The denominator population encompasses patients with ICD-9 codes for prior MI at any time and for coronary artery disease* AND CPT E/M code 99238 or 99239. Numerator coding options are shown in the chart below. See the CMS Web site for information about alternative reporting options and very helpful toolkits.

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Numerator CPT II Code Modifier

Beta-blocker prescribed 4006F none

Beta-blocker not prescribed

• Medical reason 4009F -1P

• Patient reason 4009F -2P

• System reason 4009F -3P

• Unspecified reason 4009F -8P

*The ICD-9 code for prior MI is required. The ICD-9 code for coronary artery disease may also be included but is not required for inclusion in the measure.

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ACP Hospitalist provides news and information for internists about the practice of medicine and reports on the policies, products and activities of ACP. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated