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PERFORMANCE MEASURE
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– PERFORMANCE MEASURE SETS –
Physician Voluntary Reporting Program – 2006

logo for Center for Medicare and Medicaid ServicesAs part of its overall quality improvement efforts, CMS launched the Physician Voluntary Reporting Program (PVRP) in January 2006. This voluntary Quality initiative captures data about the quality of care provided to Medicare beneficiaries only. Reporting of quality measures, linked to submission of physician billing/transaction claim forms, via specified CPT Category II codes and/or G-codes became effective April 1, 2006.

Physicians can report on the PVRP measures regardless of whether or not they register their intent to participate. However, CMS is strongly encouraging physicians to register their intent to participate in the PVRP through the secured link http://www.qualitynet.org, which provides physicians with confidential feedback on their reporting rate and performance rate for each measure.

  • •  PVRP Likely Not "Voluntary"

    The PVRP was presented by CMS as a voluntary program. However, political winds driving health policy clearly indicate an intent to coerce all physicians to participate in the PVRP. May 18, 2006 statements from CMS indicated

    ". . no definitive plans at this time" to associate financial incentives with the PVRP, and "no current plans to transform PVRP into a a Pay-for-Performance (P4P) demonstration" [PDF, p7].

    However, within 4 months of the release of PVRP codes and performance measures, the Administration's announced plans on July 28, 2006,

    "to reverse a 5% Medicare physician payment cut scheduled for next year under the condition that doctors report data enabling the agency to measure the quality of their care."

  • •  36 NQF-approved Performance Measures in PVRP

    The PVRP in 2006 consists of 36 evidence-based clinically valid measures that were endorsed by physicians and their specialty societies following extensive input and feedback from quality care experts that included physicians. The initial selection of measures include primary care measures based on National Quality Forum (NQF) approved measures that comprise the Ambulatory Care Quality Alliance (AQA) starter set. Simultaneously, these measure are intended for use by Quality Improvement Organizations (QIO) for physician quality improvement in its eighth Scope of Work (8th SOW).1

  • •  Starter Set of 16 Measures

    In an effort to decrease reporting burden, CMS excerpted a 16 Measure Core Starter Set from the 36 Full Measure Set. The topics of these 16 measures parallel but do not replicate the Hospital Quality Measures [PDF], but similarities are apparent. These measures are NOT specialty specific. Despite the small starter set of 16 measures, the PVRP maintains its same scope of coverage for many physician specialties. In fact, it is anticipated that reporting of certain G codes or CPT II codes will be predominated by physicians in certain specialties.


    1  The 8th Scope of Work is a contractural guide for the work of the QIOs for the three-year cycle beginning in August 2005. Detailed information on it is available at the American Health Quality Association AHQA website, the trade organization representing QIOs. [Word .Doc]


The 16 PVRP measures are defined below. Greater detail and in-depth understanding are provided in the discussion of HIPAA Standard Codes & PVRP codes (G-codes and CPT category II codes).

16 PVRP CORE STARTER SET MEASURES
Adapted from CMS G-Code Specifications and Instruction [PDF]

Performance Measure CMS Intent / Instructions
1.Aspirin at arrival for acute myocardial infarction

[DEMONSTRATION of numerator (G-codes and/or CPT Category II codes) and denominator (ICD-9 and E&M codes) used for measure]
This is a visit-level measure that is anticipated to be reported at each visit. To report this measure use the appropriate quality G-code indicator, the listed ICD-9, and CPT codes when providing care for a patient with acute myocardial infarction. It is anticipated that the patient would receive aspirin therapy upon initial arrival if clinically appropriate. However, the timeframe for this measure includes the entire 24 hour period before presentation and the 24 hour period from the time of presentation. This construct is consistent with the hospital performance measure. This measure is intended to reflect the quality of services provided for the initial, primary management of patients with acute myocardial infarction who present to the emergency department or the hospital setting. Thus, it is anticipated that the clinician providing the services in the emergency department or hospital will submit this measure.
2.Beta blocker at time of arrival for acute myocardial infarction

[DEMONSTRATION of numerator (G-codes and/or CPT Category II codes) and denominator (ICD-9 and E&M codes) used for measure]
This is a visit-level measure that is anticipated to be reported at each visit. It is anticipated that the patient would receive beta-blocker therapy upon initial arrival if clinically appropriate. However, the timeframe for this measure includes the entire 24 hour period from the time of presentation. This construct is consistent with the hospital performance measure. This measure is intended to reflect the quality of services provided for the initial, primary management of patients with acute myocardial infarction in the emergency department or hospital setting. Thus, it is anticipated that the clinician providing the services in the emergency department or hospital will submit this measure.
3.Hemoglobin A1c control in patient with Type I or Type II diabetes mellitus

[DEMONSTRATION of numerator (G-codes and/or CPT Category II codes) and denominator (ICD-9 and E&M codes) used for measure]
This is a patient-level measure that is anticipated to be reported a minimum of once per reporting quarter for patients seen during the reporting quarter. It is anticipated that clinicians providing services for the primary management of diabetes mellitus will submit this measure.
4.Low-density lipoprotein control in patient with Type I or Type II diabetes mellitus
This is a patient-level measure that is anticipated to be reported a minimum of once per reporting quarter for patients seen during the reporting quarter. It is anticipated that clinicians providing services for the primary management of diabetes mellitus will submit this measure.
5.High blood pressure control in patient with Type I or Type II diabetes mellitus
This is a patient-level measure that is anticipated to be reported a minimum of once per reporting quarter for patients seen during the reporting quarter. It is anticipated that clinicians providing services for the primary management of diabetes mellitus will submit this measure.
6.Angiotensin-converting enzyme inhibitor or angiotensin-receptor blocker therapy for left ventricular systolic dysfunction
This is a patient-level measure that is anticipated to be reported a minimum of once per reporting quarter for patients seen during the reporting quarter. This measure is intended to reflect the quality of services provided for the primary management of patients with heart failure and decreased left ventricular systolic function. The left ventricular systolic dysfunction may be determined by quantitative or qualitative assessment. Examples of a quantitative or qualitative assessment would be an echocardiogram that provides a numerical value of left ventricular systolic dysfunction or that uses descriptive terms such moderate or severely depressed left ventricular dysfunction.
7.Beta-blocker therapy for patient with prior myocardial infarction
This is a patient-level measure that is anticipated to be reported a minimum of once per reporting quarter for patients seen during the reporting quarter. This measure is intended to reflect the quality of services provided for the primary management of patients with coronary artery disease.
8.Assessment of elderly patients for falls
This is a patient-level measure that is anticipated to be reported only on an annual basis for patients seen during the reporting year. To report this measure use the appropriate quality G-code indicator and E&M service codes when providing care to geriatric patients. This measure is anticipated to reflect the services provided for the primary management of the geriatric patient. It is anticipated that the clinical assessment would include annual review of the patient's fall history as part of a medically necessary visit.
9.Dialysis dose in end stage renal disease patient
This is a patient-level measure that is anticipated to be reported a minimum of once per reporting quarter for patients seen during the reporting quarter. To report this measure use the appropriate quality G-code indicator, the listed ICD-9, and CPT codes when providing care to patients with end stage renal disease on hemodialysis. This measure is anticipated to reflect the services provided for the primary management of end stage renal disease. It is not anticipated that this measure would be applicable for services not related to the primary management of end stage renal disease.
10.Hematocrit level in end stage renal disease patient
This is a patient-level measure that is anticipated to be reported a minimum of once per reporting quarter for patients seen during the reporting quarter. To report this measure use the appropriate quality G-code indicator, the listed ICD-9, and CPT codes when providing care to patients with end stage renal disease on hemodialysis. This measure is anticipated to reflect the services provided for the primary management of end stage renal disease. It is not anticipated that this measure would be applicable for services not related to the primary management of end stage renal disease.
11.Receipt of autogenous arteriovenous fistula in end-stage renal disease patient requiring hemodialysis
This is a patient-level measure that is anticipated to be reported a minimum of once per reporting quarter for patients seen during the reporting quarter. To report this measure use the appropriate quality G-code indicator, the listed ICD-9, and CPT codes when providing care to patients with end stage renal disease on hemodialysis. It is anticipated that the clinician providing vascular access for the patient's hemodialysis would submit this measure for their patients. It is anticipated that clinicians will still make clinical determinations at the individual level regarding whether a patient is an appropriate candidate for arteriovenous fistula placement. This measure is intended for end stage renal disease patients actively receiving hemodialysis.
12.Antidepressant medication during acute phase for patient diagnosed with new episode of major depression
This is a patient-level measure that is anticipated to be reported a minimum of once per reporting quarter for patients seen during the reporting quarter. To report this measure use the appropriate quality G-code indicator,, the listed ICD-9, and E&M service codes for a patient that is placed on prescription therapy for the treatment of a new episode of major depression disorder. It is anticipated that the clinician that provides the primary management of depression for the patient would submit this measure. Report G8126: 1) For all patients with a diagnosis of Major Depression, New Episode who were prescribed a full 12 week course of antidepressant medication OR 2) At the completion of a 12 week course of antidepressant medication.
13.Antibiotic prophylaxis in surgical patient
This is a visit-level measure that is anticipated to be reported at each visit. To report this measure use the appropriate quality G-code indicator and the listed CPT codes when providing care to a patient undergoing surgery that typically requires the administration of prophylactic antibiotics. It is anticipated that this measure should reflect the management of the surgical patient to reduce complications from infections. Thus, it is anticipated that the clinician performing the surgery will submit this measure.
14.Thromboembolism prophylaxis in surgical patient
This is a visit-level measure that is anticipated to be reported at each visit. To report this measure use the appropriate quality G-code indicator and the listed CPT codes when providing care for surgical patients in an effort to prevent the complications of thromboembolism. It is anticipated that the clinician providing primary management of the surgical patient would submit this measure. It is anticipated that thromboembolism prophylaxis includes low-dose unfractionated heparin, low molecular weight heparin, graduated compression stockings, intermittent pneumatic compression devices, factor Xa inhibitor and warfarin. The appropriate use of thromboembolism prophylaxis will vary according to the surgical procedure.
15.Use of internal mammary artery in coronary artery bypass graft surgery
This is a visit-level measure that is anticipated to be reported at each visit. To report this measure use the appropriate quality G-code indicator and the listed CPT codes when providing care for a patient undergoing coronary artery bypass graft surgery. This measure is intended to reflect the quality of the surgical services provided for CABG patients. This measure does not include patients undergoing a repeat coronary artery bypass graft surgery. [CMS does not specifically state it, but it would appear that the clinician performing the surgery would submit this measure.]
16.Pre-operative beta-blocker for patient with isolated coronary artery bypass graft
This is a visit-level measure that is anticipated to be reported at each visit. This measure should reflect the primary management of the surgical patient undergoing isolated coronary artery bypass surgery. The time frame for this measure includes the entire 24 hour period before the incision time. [CMS does not specifically state it, but it would appear that the clinician performing the surgery or providing primary management for the surgery would submit this measure.]

The PVRP program might well be viewed as a parallel program to the hospital-based Health Quality Initiative. Initially an entirely voluntary hospital initiative in 2003, the hospital initiative was changed by federal legislators, who attached such powerful financial incentives to it that participation in the reporting program became "quasi-mandatory." Indeed, failure of hospitals to participate and comply with facility-identified performance in Hospital Compare public reporting of Health Quality Measures (20 in 2005 and 22 in 2007) [PDF] was tied to 0.4% financial disincentive in 2004, (as defined by the Medicare Prescription Drug and Modernization Act of 2003), and to 2% financial disincentive in 2005, (as defined by the Deficit Reduction Act of 2005).

Even as it has been launched, the PVRP appears destined to follow the HQI model that links non-participation to substantial financial disincentives. Whether other changes are planned for PVRP is unclear. CMS claims that the PVRP is "is intended for the confidential feedback reports and is not intended to be shared with the public," [PDF, p7], but amid the public cry for greater transparency in healthcare and expressed public outrage regarding reported medical errors, only time will tell if legislators will continue to redesign the PVRP similar to the way in which they have altered the hospital HQI.

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