As someone who is responsible for coming up with practical solutions to comply with complex requirements, I have been observing the online debate over the Medicare PQRS, Medicare MPPR, and Medicare Functional Limitation Reporting programs with a lot of interest. I have got to say, most of the interactions are not helpful and are usually a litany of indignant complaints along the lines of:
- How dare Medicare ask us for additional information on the functional capacity and improvement of our patients?
- We are underpaid already. You mean they are going to reduce our reimbursement for multiple procedures done during the same visit?
- PQRS is a pain in the butt.
I agree with most of you that the Functional Limitation Reporting program is flawed, that our profession is far from being overpaid for providing valuable services, and that the PQRS program is a pain in the butt that does little to promote quality. But, I don’t believe that my complaint about these programs offers our colleagues any useful information or any practical help.
One of our mantras at Clinicient is Assuming Good Intent. I would like to propose for the sake of discussion, that we all assume that Medicare’s intent is good. Assuming good intent, what should we do about MPPR, PQRS, and Functional Limitation Reporting?
In an earlier series of blog posts, I tried to take a fresh look at these issues by asking everyone to look at this from Medicare’s perspective. As I stated before, we have some problems because CMS has no way to know whether or not we provide quality and value. Here is why:
- The only classification system we have for our patients is based on a disease model (ICD-9). But, we don’t cure diseases, we work to help our patients improve function that may be caused by disease or injury. (Trivia question… how many ICD-9 codes include the term “gait”? Answer: one.)
- The procedure codes that we use to indicate the services we provide (CPT) were developed by physicians. Many of the 97xxx CPT codes used by PT and OT are 15 minute time based codes. So, to accurately charge for services provided for a visit longer than 15 minutes, multiple procedure codes must be used. Consequently, the MPPR process greatly affects our reimbursement. We tend to get paid for how much we do (multiple procedures), not what we know (complex decision making).
- The overall cost for our services compared with the rest of health care is small, but it is growing rapidly.
So, let’s assume good intent from CMS and that there are a bunch of smart people working there, and that they understand some of these issues:
- The value we bring to our patients is poorly understood
- The information we provide on claim forms is not an indicator of patient function or of the true value of the services we provide
- They have seen examples of rampant abuse and over utilization in our profession
- They have a responsibility to assure that our patients are receiving quality care
So, CMS has a problem and the only information they get from us on a routine basis comes off of our claim forms. It makes sense that they have designed claims based systems to try to get better information and provide better incentives.
As a result, CMS has created a system to incentivize providing quality services (PQRS) and a mechanism for describing functional improvement (Functional Limitation Reporting) that can be reported on claims in the form of special procedure codes (PQRS codes, Functional Limitation Reporting Codes).
I agree with everyone else about the PQRS pain in the butt and the multiple flaws in the Functional Limitation Reporting, but these programs may be, just may be, a step in the right direction.
Your comments are welcome.