Bulletin Number: xxxxxx

To view this page ensure that Adobe Flash Player version 9.0.124 or greater is installed.

Please login or register to make a comment!

MLN Matters Number: MM4183 Related Change Request (CR) #: 4183 Related CR Release Date: December 23, 2005 Effective Date: January 1, 2006 Related CR Transmittal #: R35DEMO Implementation Date: January 3, 2006 Note: This article was revised on June 20, 2006. Please note the special cIntroduction d section that has been added to the article on this page. Also, CMS has released CR5036 and related MM5036, which announces that CPT II codes are available for certain measures.

Physician Voluntary Reporting Program (PVRP) Using Quality G-Codes Provider Types Affected Physicians and other health care providers who bill Medicare Introduction In January of 2006, the Centers for Medicare & Medicaid Services (CMS) launched the Physician Voluntary Reporting Program (PVRP) with a core starter set of 16 measures. Collection of data on the 16 measures is currently underway. CMS is now encouraging physicians to register their intent to participate in the PVRP through the secured link http:// www.qualitynet.org .

Physicians can continue to report on the PVRP measures regardless of whether they register their intent to participate or not. However, by registering their intent to participate, physicians will be able to receive confidential feedback on their reporting rate and performance rate for each measure that ... more. less.

they reported on. Registering the intent to participate is the first step to registering for the feedback report. In June, CMS will begin contacting the individuals responsible in each physician office for completing the registration for the feedback report. CMS will walk these individuals through finishing the confidential registration process. By registering the intent to participate now, physician offices not only have the benefit of receiving feedback reports on the PVRP measures, CMS will also help their office in June with completing the full registration for the feedback reports. CMS is strongly encouraging physicians to register their intent to participate by April 1 st . The physician feedback reports will first be available in December 2006 and is based on second quarter data, which will be collected from April 1 st through June 30 th . Although registration of intent will be welcome after April 1 st , CMS strongly encourages physicians to register their intent to participate by April 1 st so that feedback reports can be based on as much data collected in the second Disclaimer This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article ma y contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of ei ther the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. Page 1 of 8 MLN Matters Number: MM4183 Related Change Request Number: 4183 Disclaimer This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article ma y contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materi als for a full and accurate statement of their contents. Page 2 of 8 quarter as possible. Again, physicians can continue to submit data on PVRP measures whether they register their intent or not. However, registering the intent by April 1 st will enable CMS to provide feedback reports based on the most information available for quarter 2. Registration of intent to participate does not obligate a physician to participate as CMS understands that unpredictable future events may occur that would ultimately prevent one from actually participating. Also, physicians can submit data on the PVRP measures without registering their intent to participate. To reiterate, CMS strongly encourages all physicians to register their intent to participate by April 1 so that: " We can help physician offices in June with completing the full registration for the feedback reports; " The physician 9s feedback reports available in December 2006 reflect the most information available for the second quarter, April 1 st 3 June 30 th ; and " Physician offices will be able to receive feedback reports on their reporting and performance rates for the PVRP measures for which information was submitted. Provider Action Needed This article provides information about the CMS 9 Physician Voluntary Reporting Program (PVRP). It will assist physicians in understanding this new voluntary reporting program and the use of G-codes to report data about the quality of care provided to Medicare beneficiaries. Background As part of its overall quality improvement efforts, CMS is launching the Physician Voluntary Reporting Program (PVRP). This new program builds on Medicare 9s comprehensive efforts to substantially improve the health and function of our beneficiaries by preventing chronic disease complications, avoiding preventable hospitalizations, and improving the quality of care delivered. Under the voluntary reporting program, physicians who choose to participate will help capture data about the quality of care provided to Medicare beneficiaries, in order to identify the most effective ways to use the quality measures in routine practice and to support physicians in their efforts to improve quality of care. Voluntary reporting of quality data through the PVRP will begin in January 2006. National Consensus Measures and Indicators To this end, CMS has begun the process of developing a comprehensive set of national consensus measures and indicators that will allow physicians to more MLN Matters Number: MM4183 Related Change Request Number: 4183 Disclaimer This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article ma y contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materi als for a full and accurate statement of their contents. Page 3 of 8 efficiently report quality information on the health services provided to Medicare beneficiaries. CMS has identified 36 evidence-based clinically valid measures that have been part of the guidelines endorsed by physicians and the medical specialty societies and are the result of extensive input and feedback from physicians and other quality care experts. However, after announcing the PVRP on October 28, 2005, suggestions have been made by several physician organizations to identify a starter set in order to lessen the potential reporting burden for physicians and better align the PVRP with other quality measurement activities affecting physicians. CMS has decided to adopt the suggestion of a smaller core starter set of PVRP measures. The core set consists of 16 measures, which will significantly reduce the number of measures applicable to any individual physician practice specialty. Additionally, we have selected primary care measures based on measures that are National Quality Forum (NQF) endorsed, part of the Ambulatory Care Quality Alliance (AQA) starter set, and that will be used by the Quality Improvement Organization (QIO) programs for physician quality improvement in its eighth Scope of Work (8th SOW). Despite the smaller starter set of 16 measures, the PVRP maintains its same scope of coverage for physician specialties. Confidential reports available to physicians will be limited to the 16 core starter set. Physicians may report clinical data on the remaining 20 measures, but will not receive summarizing reports. Moreover, CMS is developing the underlying infrastructure so that the reporting of these measures on existing physician claims could begin as soon as January 1, 2006. Data Collection Through the Administrative Claims System The usual source of the clinical data for quality measures is retrospective chart abstraction, but data collection through chart abstraction can be quite burdensome. Additionally, while electronic health records may ultimately greatly facilitate clinical data reporting, they do not, at present, provide a widespread means for physicians to report clinical data. Therefore, to avoid the necessity for chart abstraction, CMS will start the process of collecting quality information on services provided to the Medicare population by using the administrative claims system. G-Codes Specifically, CMS has defined a set of HCPCS codes (termed G-codes) to report data for the calculation of the quality measures. These new codes will supplement the usual claims data with clinical data that can be used to measure the quality of services rendered to beneficiaries. MLN Matters Number: MM4183 Related Change Request Number: 4183 Disclaimer This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article ma y contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materi als for a full and accurate statement of their contents. Page 4 of 8 CMS currently has 16 sets of specialty measures. Additional measures to cover a broader set of specialties will be developed over the next few payment cycles. Each measure has a defined numerator (the appropriate G-code) and a denominator (specifically defined according to the appropriate services or condition). The reporting rate is calculated as a percentage for each of the 16 measures. You can use G-codes when all of the following circumstances are met: " The G-code reported on the claim relates to a covered diagnosis, covered treatment(s), or covered preventive service(s) that are applicable to the beneficiary. " The G-code is directly relevant to the specific service(s) provided to the beneficiary by the practitioner reported on the claim. " The G-code represents medically necessary and appropriate medical practice under the circumstances. " The basis for the G-code is documented in the beneficiary medical record. Important Points for Physicians " When applicable, the G-code should be reported in addition to CPT and ICD- 9 codes required for appropriate claims coding. " They do not substitute for CPT and ICD-9 codes requirements for payment. " They are not associated with a separate fee, and will not be individually compensated. " G-codes are always billed in conjunction with a service and are never billed independently. " The G-codes should be reported with a submitted charge of zero ($0.00). (G- codes will not appear on the Medicare Physician Fee Schedule Data Base (MPFSDB) because there are no relative value units (RVUs) or amounts for these codes.) " They are not specialty specific . Therefore, a medical specialty may report G-codes classified under other specialties. However, it is anticipated that the reporting of certain G-codes will be predominated by certain specialties. " The failure to provide a G-code will not result in denial of a claim that would otherwise be approved, and thus submission of a G-code is voluntary. Although reporting is voluntary, CMS is encouraging physicians to submit G codes when applicable. The PVRP 9s objective is to provide CMS with data that it can use to calculate quality measures. Therefore, CMS will calculate the reporting rate for physicians who participate in the program, and will provide them with feedback MLN Matters Number: MM4183 Related Change Request Number: 4183 Disclaimer This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article ma y contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materi als for a full and accurate statement of their contents. Page 5 of 8 information in an effort to assist them in improving their data accuracy and reporting rate. Additional Information The specific quality measures related to the G-codes in this initial program launch are reflected in the table at the end of this article. Please note that MM5036 has modified this table to include CPT II codes that can be used instead of the noted G-codes. Also note that either a G-code or a CPT II code, should be submitted, but never both. MLN article may be reviewed at http://www.cms.hhs.gov/MlnMattersArticles/downloads/MM5036.pdf on the CMS website. More information about PVRP and quality G-Codes and CPE can be found in CR5036 is available at http://www.cms.hhs.gov/Transmittals/downloads/R43DEMO.pdf on the CMS website. You can find more information about the physician voluntary reporting program and quality G-Codes by going to http://www.cms.hhs.gov/Transmittals/downloads/R35DEMO.pdf on the CMS website. Appendices accompanying CR4183 contain the specific G-Codes and their descriptors as they relate to the developed quality measures reflected in the above table. The transmittal will list both the 36 proposed measures and the 16 measures which will be used initially in the PVRP. Finally , if you have any questions, please contact your Medicare carrier at their toll-free number, which may be found at http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS website. MLN Matters Number: MM4183 Related Change Request Number: 4183 Disclaimer This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article ma y contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materi als for a full and accurate statement of their contents. Page 6 of 8 Physician Voluntary Reporting Program G-Codes and Descriptions for Clinical Measures Measure G-Code/Descriptions Aspirin at arrival for acute myocardial infarction G8006 : Acute myocardial infarction: patient documented to have received aspirin at arrival measure G8007 : Acute myocardial infarction: patient not documented to have received aspirin at arrival G8008 : Clinician documented that acute myocardial infarction patient was not an eligible candidate to receive aspirin at arrival Beta blocker at time of arrival for acute myocardial infarction G8009 : Acute myocardial infarction: patient documented to have received beta-blocker at arrival G8010 : Acute myocardial infarction: patient not documented to have received beta-blocker at arrival G8011 : Clinician documented that acute myocardial infarction patient was not an eligible candidate for beta-blocker at arrival measure Hemoglobin A1c control in patient with Type I or Type II diabetes mellitus G8016 : Diabetic patient with most recent hemoglobin A1c level (within the last 6 months) documented as less than or equal to 9% G8015 : Diabetic patient with most recent hemoglobin A1c level (within the last 6 months) documented as greater than 9% G8017 : Clinician documented that diabetic patient was not eligible candidate for hemoglobin A1c measure G8018 : Clinician has not provided care for the diabetic patient for the required time for hemoglobin A1c measure (6 months) Low-density lipoprotein control in patient with Type I or Type II diabetes mellitus G8020 : Diabetic patient with most recent low-density lipoprotein (within the last 12 months) documented as less than 100 mg/dl G8019 : Diabetic patient with most recent low-density lipoprotein (within the last 12 months) documented as greater than or equal to 100 mg/dl G8021 : Clinician documented that diabetic patient was not an eligible candidate for low-density lipoprotein measure G8022 : Clinician has not provided care for the diabetic patient for the required time for low-density lipoprotein measure (12 months) High blood pressure control in patient with Type I or Type II diabetes mellitus G8024 : Diabetic patient with most recent blood pressure (within the last 6 months) documented less than 140 systolic and less than 80 diastolic G8023 : Diabetic patient with most recent blood pressure (within the last 6 months) documented as equal to or greater than 140 systolic or equal to or greater than 80 mmHg diastolic G8025 : Clinician documented that the diabetic patient was not an eligible candidate for blood pressure measure G8026 : Clinician has not provided care for the diabetic patient for the required time for blood pressure measure (within the last 6 months) Angiotensin-converting enzyme inhibitor or angiotensin-receptor blocker therapy for left ventricular systolic dysfunction G8027 : Heart failure patient with left ventricular systolic dysfunction (LVSD) documented to be on either angiotensin-converting enzyme inhibitor or angiotensin-receptor blocker therapy G8028 : Heart failure patient with left ventricular systolic dysfunction (LVSD) not documented to be on either angiotensin-converting enzyme inhibitor or angiotensin-receptor blocker therapy G8029 : Clinician documented that heart failure patient was not an eligible candidate for either angiotensin-converting enzyme inhibitor or angiotensin- receptor blocker therapy measure MLN Matters Number: MM4183 Related Change Request Number: 4183 Disclaimer This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article ma y contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materi als for a full and accurate statement of their contents. Page 7 of 8 Measure G-Code/Descriptions Beta-blocker therapy for patient with prior myocardial infarction G8033 : Prior myocardial infarction 3 coronary artery disease patient documented to be on beta-blocker therapy G8034 : Prior myocardial infarction 3 coronary artery disease patient not documented to be on beta-blocker therapy G8035 : Clinician documented that prior myocardial infarction 3 coronary artery disease patient was not an eligible candidate for beta-blocker therapy measure Assessment of elderly patients for falls 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 Dialysis dose in end stage renal disease patient G8075 : End-stage renal disease patient with documented dialysis dose of URR greater than or equal to 65% (or Kt/V greater than or equal to 1.2) G8076 : End-stage renal disease patient with documented dialysis dose of URR less than 65% (or Kt/V less than 1.2) G8077 : Clinician documented that end-stage renal disease patient was not an eligible candidate for URR or Kt/V measure Hematocrit level in end stage renal disease patient G8078 : End-stage renal disease patient with documented hematocrit greater than or equal to 33 (or hemoglobin greater than or equal to 11) G8079 : End-stage renal disease patient with documented hematocrit less than 33 (or hemoglobin less than 11) G8080 : Clinician documented that end-stage renal disease patient was not an eligible candidate for hematocrit (hemoglobin) measure Receipt of autogenous arteriovenous fistula in end-stage renal disease patient requiring hemodialysis G8081 : End-stage renal disease patient requiring hemodialysis vascular access documented to have received autogenous AV fistula G8082 : End-stage renal disease patient requiring hemodialysis documented to have received vascular access other than autogenous AV fistula Antidepressant medication during acute phase for patient diagnosed with new episode of major depression G8126 : Patient documented as being treated with antidepressant medication during the entire 12 week acute treatment phase G8127 : Patient not documented as being treated with antidepressant medication during the entire 12 week acute treatment phase G8128 : Clinician documented that patient was not an eligible candidate for antidepressant medication during the entire 12 week acute treatment phase measure Antibiotic prophylaxis in surgical patient G8152 : Patient documented to have received antibiotic prophylaxis one hour prior to incision time (two hours for vancomycin) G8153 : Patient not documented to have received antibiotic prophylaxis one hour prior to incision time (two hours for vancomycin) G8154 : Clinician documented that patient was not an eligible candidate for antibiotic prophylaxis one hour prior to incision time (two hours for vancomycin) measure Thromboembolism prophylaxis in surgical patient G8155 : Patient with documented receipt of thromboembolism prophylaxis G8156 : Patient without documented receipt of thromboembolism prophylaxis G8157 : Clinician documented that patient was not an eligible candidate for thromboembolism prophylaxis measure MLN Matters Number: MM4183 Related Change Request Number: 4183 Measure G-Code/Descriptions Use of internal mammary artery in coronary artery bypass graft surgery G8158 : Patient documented to have received coronary artery bypass graft with use of internal mammary artery G8159 : Patient documented to have received coronary artery bypass graft without use of internal mammary artery G8160 : Clinician documented that patient was not an eligible candidate for coronary artery bypass graft with use of internal mammary artery measure Pre-operative beta blocker for patient with isolated coronary artery bypass graft G8161 : Patient with isolated coronary artery bypass graft documented to have received pre-operative beta-blockade G8162 : Patient with isolated coronary artery bypass graft not documented to have received pre-operative beta-blockade G8163 : Clinician documented that patient with isolated coronary artery bypass graft was not an eligible candidate for pre-operative beta-blockade measure Disclaimer This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article ma y contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materi als for a full and accurate statement of their contents. Page 8 of 8

less