Local, State, Federal

Move Now! Medicare’s Quality Initiative
Societies Weigh In On Proposed National Coverage Determination for CCTA

Move Now! Medicare’s Quality Initiative

Sheri Poe Bernard, CPC, CPC-H, CPC-P

Many providers believe that participation in Medicare’s Physician Quality Reporting Initiative (PQRI) is a waste of effort. After all, a 1.5% bonus to Medicare billings hardly covers the costs for complex PQRI reporting, and there are few measures affecting radiology. But pay for performance is not going away, and we can expect the dollars tied to performance to rise. What CMS is offering providers today is an opportunity to get paid for a dress rehearsal for what will be required tomorrow. What do you need to know in order to participate?

The time is now. The current reporting period for PQRI is January 1 through December 31, 2008. Since 80% of encounters must show compliance with PQRI reporting in order for the bonus payment to be made, physicians who haven’t begun quality reporting need to start immediately. It’s early enough in the year they can still catch up to an 80% reporting threshold.

You must report at least three measures. There are more than 100 PQRI measures, but only a few that are specific to radiology. Radiology documentation is targeted for stroke and stroke rehabilitation measures, and calls for details and timeliness in CTs, MRIs, and carotid imaging reports. Another measure seeks better care coordination among physicians for patients with osteoporosis and could be adopted by a radiologist, as well. These measures require:

  • The final reports of carotid imaging (CTA, MR, MRA, or CT) of patients with ischemic stroke or TIA must include direct or indirect reference to measurements of distal internal carotid diameter;
  • CT or MRI studies of the brain of patients with ischemic stroke, TIA, or intracranial hemorrhage be performed within 24 hours of arrival at the hospital and the associated reports document presence or absence of hemorrhage and mass lesion and acute infarct;
  • That physicians follow up with other physicians regarding patients who are suspected or confirmed to have osteoporosis. The targeted patient population includes those over 50 years of age who have sustained a hip, spine, or distal radial fracture.
  • These measures apply to all places of service.

The bonus may be bigger than you think. While the bonus limit is set at only 1.5% of total eligible Medicare billings, those billings include radiopharmaceuticals.

Volunteer while you can. The first PQRI period occurred during the third and fourth quarter of 2007, and physicians are awaiting the bonus payout for their efforts. The latest effort will traverse the entire year, with payouts occurring in 2009. The program remains voluntary at least through 2008. PQRI was designed to ensure delivery of high-quality patient care and to encourage more preventative care. Today’s program offers physicians an opportunity to gather experience in collection and reporting of quality data to prepare for the mandated performance initiatives we expect in years to come.

—Sheri Poe Bernard, CPC, CPC-H, CPC-P

Sheri Poe Bernard, CPC, CPC-H, CPC-P, is vice president of member relations at the American Academy of Professional Coders (AAPC), the nation’s largest education and credentialing association for medical coders. AAPC provides certified credentials to medical coders in physician’s offices, hospitals, and outpatient centers. The three certifications AAPC offers are CPC, CPC-H, and CPC-P, and represent the gold standard certification for medical coding.

Societies Weigh In On Proposed National Coverage Determination for CCTA

In the days before the start of the New Year, the Centers for Medicare and Medicaid Services announced its proposal for national coverage of cardiac computed tomographic angiography (CCTA)—a plan the American College of Radiology, and others in the medical community, found faulty.

The plan specifically called for coverage for the use of CCTA in Medicare beneficiaries with two clinical indications of coronary artery disease, under the Coverage with Evidence Development (CED) process. These indications encompass symptomatic patients with chronic stable angina or anginal equivalent and an intermediate pretest probability of CAD, and symptomatic patients with possible acute coronary syndrome, a low risk of short-term death, and an intermediate probability of CAD.

“Proponents of the imaging procedure believe that coronary CTA may reduce the need for invasive coronary angiography for certain patients,” the report states. “However, others have noted a lack of evidence on outcomes and limitations in the technology, including segments that may be uninterpretable and health risks from the radiation exposure.”

However, in a letter addressed to CMS, the heads of the American College of Cardiology, American College of Radiology, American Society of Nuclear Cardiology, North American Society for Cardiovascular Imaging, Society for Cardiovascular Angiography and Interventions, and the Society for Cardiovascular Computed Tomography stated they respectfully disagreed with conclusions drawn in the proposed coverage determination. The policy would have “a profoundly negative impact” on Medicare beneficiaries, they added.

“We strongly urge CMS to maintain the current coverage status for CCTA; that is, CMS should continue to allow local Medicare carriers to determine coverage through the Local Coverage Determination process,” the letter declares, pointing out that LCDs in place for the 50 states and the District of Columbia provide Medicare beneficiaries with access to an important diagnostic tool when undergoing evaluation for coronary artery disease. “The analysis presented in the proposed decision memo simply does not support establishment of what will effectively be, in practice, a national non-coverage policy for the vast majority of Medicare patients.”

But if CMS moves forward with the establishment of a national coverage policy, the societies said they recommend national coverage without requiring evidence development for the two indications the Centers had referenced, in addition to others. These include the assessment for presence and course of coronary artery anomalies, coronary artery evaluation in individuals in whom prior clinical noninvasive coronary artery test data are equivocal or discordant, assessment of bypass graft location prior to surgical intervention in patients undergoing repeat sternotomy, and coronary artery evaluation in patients undergoing noncardiac surgery.

In an argument advocating for further exploration of available published evidence, the societies emphasize the importance of a thorough and complete review. “Again, we wish to point out to the agency that approximately three-fourths of the available evidence with 64-slice CT scanners has not been considered in the draft proposal,” they wrote. “It is critically important that CMS modify its major premise used in forming the basis of the proposed NCD—the notion that CCTA must improve health outcomes.”

The societies also stipulated that existing statements define appropriate use of CCTA, clinically valuable indications for CCTA are well supported by existing evidence that was excluded from the proposed coverage, and definitions of patient populations were inaccurate. “The proposed NCD will only slow the development of evidence by academia, societies, and registries rather than accelerate it,” they wrote.

According to CMS, the proposed National Coverage Determination that was issued defined the question that studies must address, as well as the standards they must meet as a condition of coverage. Questions were centered on whether cardiac CTA has the ability to diagnose or exclude coronary artery disease as well as invasive coronary angiography, whether coronary CTA reduces the need for invasive coronary angiography, and whether coronary CTA improves health outcomes for patients with acute chest pain who present in the emergency department and other settings.

“Both CMS and the Agency for Healthcare Research and Quality believe these questions and standards meet the requirement of Section 1862(a)(1)(E) of the Medicare statute, which allows coverage in connection with certain medical research where the evidence for coverage is still preliminary but promising,” CMS stated.

Yet, the societies countered that numerous clinical trials have already proven the usefulness of CCTA and justified its coverage. An NCD with CED is not appropriate based on the sum of clinical evidence that already exists, they said, but if CMS decides to continue with its plan, the societies urged that CMS reconsider numerous elements of its proposed questions “for the purposes of making them more clinically appropriate.” If not, they said they would “fear that substantial waste of limited Medicare resources will be spent on a research endeavor that will produce little clinically useful information.”

CMS plans to issue a final National Coverage Determination in March 2008. It welcomes the public to make comments on its proposed decision by logging on to www.cms.hhs.gov/mcd/viewdraftdecisionmemo.asp?id=206. Instructions for submitting comments are available at www4.cms.hhs.gov/InfoExchange/02_publiccomments.asp#TopOfPage.

—Elaine Sanchez