2007 Medicare Bonus Incentive Program for Clinical Social Workers

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CLINICAL SOCIAL WORK PRACTICE UPDATE

2007 Medicare Bonus Incentive Program for Clinical Social Workers

Mirean Coleman, MSW, LICSW, CT
Senior Policy Associate

September 2007

Under the Tax Relief and Health Care Act of 2006, (P. L. 109–432, December 20, 2006) the Center for Medicare and Medicaid Services (CMS) established the 2007 Physician Quality Reporting Initiative, known as PQRI. This program creates a financial incentive for clinical social workers and other health care professionals to participate in an optional quality reporting program.

From July 1 through December 31, 2007, clinical social workers who are Medicare providers and who report quality measures when providing psychotherapy services, are eligible to earn a 1.5 percent bonus payment of their total allowed covered services rendered during this period. Claims may be filed electronically or on paper on the CMS-1500 Form to receive the bonus payment.

The information presented in this practice update is technical. Steps have been taken to simplify the explanation of the elements in the optional quality reporting program to make it user friendly.

Background

Medicare is transforming its payment system to a value-based purchasing program. The goals are to: (A) provide financial incentives to encourage quality care, and (B) avoid unnecessary costs to improve the value of care.

Several successful Medicare value-based pilot programs have demonstrated support for this type of incentive program. In addition, Congress, the Medicare Payment Advisory Commission (MEDPAC), and the Institute of Medicine (IOM) have expressed support for this change.

The focus of PQRI is on quality care. The program was founded on evidenced-based measures which improve care when implemented. Rewarding reported measurements with financial incentives is the first step toward pay for performance.

Quality Measures

Seventy-four quality measure statements, descriptions, and specifications are available for the reporting period of July 1 through December 31, 2007. NASW advocated for clinical social workers to have access to the quality measures assigned for this reporting period. As a result, clinical social workers have access to Measure Nine which reads as follows:

Antidepressant medication during acute phase for patients with new episode of major depression.

Since April 2007, NASW has participated in an expert work group developed by Quality Insights of Pennsylvania, a CMS contractor. This group developed three additional measures for use by clinical social workers and other mental health providers beginning in January 2008.

Each measure has two major components:

The denominator describes the eligible cases for a measure and is specified by the International Classification of Diseases, 9th Edition, Clinical Modification (ICD-9-CM) and the Current Procedural Terminology (CPT) Codes.
The numerator describes the clinical action required by the measure for reporting and performance and is specified by Category II Codes or “G” codes.

Reporting Frequency and Performance Time Frames

A reporting frequency requirement is included in each measure for each denominator of an eligible patient seen during July 1 through December 31, 2007. The reporting frequency is described as follows:
(1) Report one time only
(2) Report once for each procedure performed
(3) Report once for each acute episode

The performance time frame is defined in the measure’s description, and is distinct from the report frequency requirement. The performance time frame delineates the period during which the clinical action described in the numerator may be accomplished. Performance time frames are stated as “within 12 months, or “most recent.” This means:

The clinical action in the numerator is performed only once during the reporting period
The quality code is reported once for each patient

Descriptions and Eligible Cases

It is important to review and understand Measure Nine’s descriptions, which provide definitions and instructions for coding and reporting the measure for the bonus payment.

The descriptions for Measure Nine are as follows:

Reporting Description: Percentage of patients aged 18 years and older with Major Depressive Disorder (MDD), and an applicable G-code reported with each new occurrence of MDD during the reporting period
Performance Description: Percentage of patients aged 18 years and older diagnosed with new episode of Major Depressive Disorder and documented as treated with antidepressant medication during the entire 84-day (12 week) acute treatment phase

In order to receive the optional bonus payment, it is necessary to meet the following requirements:

Patient should be 18 years or older on the date of service
Patient should have the diagnosis of major depression (ICD-9-CM Codes: 296.20, 296.21, 296.22, 296.23, 296.24, 296.30, 296.31, 296.32, 296.33, 296.34, 298.0, 300.4, 309.1, or 311)
Patient services should have occurred during the reporting period of July 1 through December 31, 2007

Codes

Three reporting codes exist for Measure Nine. Currently, they are temporary “G” codes. They will be converted at a later date to CPT Category II Codes.

The current “G” codes are:

G8126: Patient with new episode of MDD documented as being treated with antidepressant medication during the entire 12-week acute treatment phase—This code is used when successful reporting and performance descriptions are met.
G8128: Clinician documented that patient with a new episode of MDD was not an eligible candidate for antidepressant medication treatment or patient did not have a new episode of MDD—Use this code when the reporting and performance intervention are not met; however, the clinical social worker will receive credit for reporting it.
G8127: Patient with new episode of MDD not documented as being treated with antidepressant medication during the entire 12 week acute treatment phase. With this code, the reporting intervention is met, but the performance is not.

Guidelines for Reimbursement

To receive payment for Measure Nine, it is necessary to adhere to the following guidelines:

Document all clinical actions in patient’s record.
Review the patient’s clinical data on antidepressant medication on the day of the encounter during the reporting period of July 1 through December 31, 2007 and select the appropriate “G” code.
Document the “G” code in an eligible case in the patient’s record and on the reimbursement claim form.
Report each eligible patient only once during the reporting period of July 1 through December 31, 2007.
Report G8126 for all patients with a diagnosis of Major Depression, New Episode who were prescribed a full 12-week course of antidepressant medication, or at the completion of a 12-week course of antidepressant medication. (A new episode is defined as a patient with major depression who has not been seen or treated for major depression by any practitioner in the previous four months. A new episode can be a recurrence for a patient with prior major depression or a patient with a new onset of major depression.)

Completing the Claim Form

In order to receive the bonus incentive payment, the clinical social worker can bill electronically or complete the CMS 1500 form, version 08-05. The following fields are utilized on the CMS 1500 Form.

Field 21: ICD-9-CM Codes
Field 24D : CPT, HCPCS, CPT Category II, and temporary “G” Codes with any associated modifiers
Field 24E: Diagnosis pointer
Field 24J: Rendering provider’s National Provider Identifier (NPI)
Field 25: Employer’s Tax Identification Number (TIN)

Data Submission

Clinical social workers should file their claims promptly to qualify for the bonus incentive payment. February 28, 2008 is the final date that claims can be submitted and included in the analysis for the period of July 1 through December 31, 2007.

Additional information about the Physician Quality Reporting Initiative is available on the following CMS Web pages: