Coding Strategy

Here are the pros and cons to help guide your decision.

Question: Our practice is considering accepting patients with PFFS plans. We’re heard that some patients are starting to have them, but we’re not sure whether we’re going to accept them or not. Are PFFS plans beneficial for us?

Answer: PFFS are Private Fee-for-Service plans, which are non-network plans. These plans let members receive care from any doctor or hospital that accepts the plan’s payment terms and conditions.

If your practice decides to accept these terms, you would become a “deemed” provider. Plan members can receive covered services from any deemed provider in the U.S. However, member patients must confirm that the provider is deemed every time a service is provided.

PFFS plans are different from Medicare Advantage plans because they do not require a doctor or hospital to contract with a health plan to provide services. This means that doctors or hospitals that do not agree to the PFFS plans’ terms and conditions may choose not to provide health care services to a plan member, except in emergencies.

Coming soon: Starting in 2011, PFFS plans will have to measure and report on their providers’ quality of care. But the catch is that they’ll also have to form provider networks with contracts.

In counties where there are two or more non-PFFS plans, PFFS plans will no longer be able to simply “deem” providers into the plan without a contract. Under current law, PFFS plans don’t have to prove they can meet access standards if they allow any willing qualified Medicare provider to participate, and they pay as traditional Medicare would pay.

One argument is that the network requirement would provide better access to care because there would be contracts between the providers of services and the plan. On the other hand, private FFS plans may limit the number of providers who participate, actually resulting in poorer access to care.

@ Medical Office Billing & Collections Alert (Editor: Joshua Thines).

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Plus, experts at the AMA meeting in Chicago tell you what to do if you can’t get H1N1 vaccine for PQRI Measure 110 or other vaccine measures.

Question: My internist decided not to put a patient on Coumadin because the patient has a higher risk of falling than from having a stroke. Our group participates in PQRI easure 33 for risk of clotting. How can I indicate performing the measure wasn’t appropriate so that the physician isn’t penalized for not prescribing the anti-blood clotting medication?

Answer: You should report the measure and append the denominator exclusion indicator 1p. This indicator shows the physician chose not to prescribe the drug due to the art of medicine, or factors that make performing the measure not clinically appropriate.

If, however, the internist prescribed Coumadin but the patient isn’t taking it because she can’t afford the medication, you instead would use 2P. Your group can then have the patient referred to a social worker to help the patient figure out her financial hardship and find a way to obtain the medically necessary drug.

The third denominator exclusion in this group is 3p, which shows the medication was not available. Read on to learn what to do when you can’t get H1N1 vaccine supply …

For instance, if you’re reporting on giving H1N1 vaccine, but no product was available since delivery mechanisms sent the vaccine to clinics, not your practice, you could use the universal vaccine measure 110 with 3P for no vaccine available.

These three exclusion denominators show why things like art of medicine, education, or economic reason prevented the physician from performing a given measure, explained Susan Nedza, MD, MBA, FACECP, at the final session of the AMA CPT 2010 symposium. The patients who fall under these reasons do not effect physician’s quality of care percentage as shown in a registry for an individual’s or group’s measure.

“Physicians for the most part are receptive to using these now,” reported Ronald A. Gable, MD, CPT Performance Measures Advisory Group, in the PQRI presentation in Chicago. Denominator exclusions used to be a negative allowing physician to say why opted out of a measure. Now they are a positive that indicates why performing the measure was not appropriate so that quality of care percentage not negatively impacted.

—by Jennifer Godreau

AUDIO TRAINING EVENT: 2010 Primary Care Coding & Reimbursement Update. With Jill Young.

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