PQRI: What every dermatologist should know about Medicare's new quality initiative

August 1, 2007

National report - At the urging of advocacy groups and large corporations, the Centers for Medicare and Medicaid (CMS) has launched a six-month, temporary initiative that will be the first step in measuring health care quality against health care dollars spent.

National report - At the urging of advocacy groups and large corporations, the Centers for Medicare and Medicaid (CMS) has launched a six-month, temporary initiative that will be the first step in measuring healthcare quality against healthcare dollars spent.

The payment is calculated based on the number of patients seen and will probably amount to about $2,500 for the average dermatologist. The pay-for-performance (also called P4P) project began July 1 and will run through Dec. 31, 2007, but dermatologists can begin reporting at any time.

Among these, three measures for melanoma were approved by the American Medical Association (AMA) and AQA Alliance (formerly known as the Ambulatory Care Quality Alliance) because patients are primarily in a Medicare population, there exists a gap in care and a variation in practice, and there is a potential for savings.

Although PQRI in its current form is only approved for 2007 and 2008, the demand for quality measures for dollars spent will absolutely continue to exist in some form, according to Dirk Elston, M.D., a dermatologist at Geisinger Medical Center in Danville, Pa., co-chairman of the AMA Pay for Performance Workgroup and American Academy of Dermatology adviser to the CPT Editorial Panel.

"With all quality measures, there are things that - in an ideal world - physicians should be doing anyway," Dr. Elston tells Dermatology Times. "If you get a group of physicians together and talk about quality, there are certain things that any prudent physician would agree upon, yet there is published data that says they often are not being done.

"Quality measures ensure that for important things like melanoma, all of the i's are dotted and all of the t's are crossed."

Robert T. Brodell, M.D., believes that the financial enticement might persuade dermatologists to take part in PQRI.

"There is evidence that physicians act to serve their patients' needs more effectively when financial incentives are provided," he says. "The challenge is identifying similar measurable endpoints for dermatology that will really make a difference."

PQRI: The how to's

Getting on board with PQRI is simple: You report the three quality measures for at least 80 percent of melanoma patients to receive a modest bonus reimbursement from Medicare.

To qualify, dermatologists must perform the service, document it in the medical record, and code the CPT II codes: 1050F for history of new or changing mole; 2029F for full skin exam; and 5005F for counseling patients to do self-exam.

Specifically, dermatologists will use the Category II code for the three measures and document it in the same place as any other CPT procedure code. Categories include history, physical exam and intervention. If a patient declines for various reasons such a language barrier or he or she is blind, that information can be reported using one of three modifiers (1P for a medical reason, 2P for a patient reason, 3P for a systems reason such as the measure being performed by another physician).

The program is completely voluntary. No beneficiary co-pay or notice will be sent to the beneficiary about the bonus payments. There is no penalty for not participating, and non-participation will not be recorded or reported to anyone.

The current program is designed to be revenue-neutral, but Dr. Elston believes that additional money should be spent to cover the costs involved with quality measures.