Documenting PQRS
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Documenting PQRS

I encourage impaneled practitioners of Acupuncture and Oriental Medicine to consider documenting the Physician's Quality Reporting Systems's (PQRS) "quality measure" codes for Primary Care & Prevention on insurance forms. We can do this in New Mexico because we are considered "Primary Care Providers", so by definition we are supposed to. Look at what Primary Care & Prevention means then examples of how Traditional Chinese Medicine (TCM) is already accountable:

Prevention of Disease & Disability
Assessment of risks: lifestyle, diet, habits, genetics etc. Example1: Women are susceptible to disease of blood vacuity; men to diseases of qi repletion. Example 2: A longitudinal study demonstrated how Gui Lu Er Xian Jiao was as effective as Fosamax in preventing the progression of and reversing osteoporosis.

Early Screening, Detection & Intervention
Signs of chronic disease surface in mid-life between the ages of 40 and 65 years. The earlier a disease is identified, the easier it is to treat with the results better than those obtained after delayed treatment. For example central obesity in the abdomen and flank is associated with metabolic syndrome (obesity, hypertension, insulin-resistance, cardiovascular disease). Men are prone to abdominal obesity and metabolic syndrome. Apple-shaped means upper body obesity. Pear-shaped means lower body obesity.  Example1: Looking for patterns of disease associated with Shao Yang (healthy), Shao Yin (ectomorph), Tai Yin (pear-shaped females), and Tai Yang (apple-shaped males with skinny extremities).  Example 2: Certain patterns of disease are more likely at certain stages of life such that In children look to the Kidney; if over 40 look to the Liver; in elders look to the Spleen. 

Restoration of Health After Illness
Prevent further insult & injury, stabilize deterioration, and restore function. Example: When preparing a patient for, or helping them recovery from chemotherapy, considering that Jie Xue Teng is beneficial for chemo-induced neutropenia, and Scutalleria Decoction is in clinical trials for chemo-induced nausea & vomitIng,  

Why Document Quality Measures?
This is not about ICD ad CPT codes [See Coding Primary Care]. PQRS is a CMS program whereby an incentive payment is made to health professionals who report data on various quality measures; or penalized for not beginning in the near future. There is no risk to TCM providers because we are not on the eligibility list to be rewarded or penalized as Western medicine providers are. 
Documentation is rather, a way to earn increased credibility and visibility with insurance companies by letting them know we are aware of and can address the same PQRS quality measure (for e.g. pre-hypertension, and stage 1 hypertension) as the Western providers. This is a very important aspect of health care reform. PLUS, It benefits the system of care; and justifies through accountability, requests for impanelment and/or better insurance reimbursement.

Documenting Quality Measures 101
The documentation is somewhat easy if you consistently choose one of the PQRS quality measure for situations that you frequently address in your practice. For example the alcohol & smoking cessation education and intervention is appropriate if you provide the National Acupuncture Detoxification Association (NADA) protocol. The insurance companies do not ask for specifics, only a code for: teaching, screens (e.g. MATS/ DATSSMAST-GCAGE & AUDIT, T-ACE, TEAK);  preventive measures and intervention. Not official diagnostic language such as  "LV Depression/Qi Stagnation and Yin Deficiency". 

Another example is the quality measure "Screening / Therapy for Osteoporosis for Women 65 Years and Older".  I would not have to say this involved pattern discrimination, tongue & pulse analysis... for a diagnosis of Jing Deficiency and Liver/Kidney Yin Deficiency. Nor that the intervention were instructions on qi gong exercises, and a prescription for Gui Lu Er Xian Jiao. Just a code for fulfilling the quality measure. Then documentation in the chart of the Western diagnosed osteoporosis (a copy of the DEXA scan report), and/or or of administering the  Fracture Risk Assessment Score (which estimates the risk for osteoporotic fractures in women).

"Acupuncture Treatment Guidelines" are accessible through the American Acupuncture Council Network (AAC). How is this important? Well, it places acupuncture in line with Western medicine's" Standards of Care", which are based on guidelines produced by various specialist organizations. The guidelines, which are disease or disability specific, are used by individual care providers to create their own protocols which they use in practice. In Primary Care practice there are guidelines for such things such as  obesity hypertension, cardiovascular  diseases, diabetes, osteoporosis, smoking cessation, depression etc. 

There are many free sources of Western medicine guidelines. The National Guideline Clearing House is only one of them. Here is their guideline for Low Back Pain.  If a DOM (1) evaluates/ re-evaluates the patient, (2) educates on preventive measures, (3) implements a "Management/ Treatment" option, (4) considers the "Major Outcome Goals" , and/or (5) refers appropriately then they have both followed a guideline (scroll way down to see the actual recommendations) and fulfilled the PQRS quality measure called " Back Pain Measures Group" which entails:
  • Initial Visit 
  • Physical Exam 
  • Advice for Normal Activities 
  • Advice Against Bed Rest 
While herbal therapy is on the NGC low back pain guideline, I think it is limiting and misleading to qualify devil's claw, willowbark, and capsicum as the primary herbals. This reflects an inadequate evaluation of herbal medicine. I do not think these herbs would be the first line choice of a Western or Eastern medicine herbalist. So also use your Chinese Medicne expertise when evaluating Western guidelines. 

Acupuncture is indeed on the NGC guideline list for the management of acute and chronic low back pain "as a stand-alone therapy or as an adjunct to an overall active treatment program". However there are no specifics. The AAC Low Back Pain guideline is acupuncture specific. Meaning it provides parameters in the following areas:

  • Indication for acupuncture 
  • Time to produce effect with acupuncture
  • Frequency of acupuncture treatments needed
  • Optimum vs. Maximum duration of treatment

I may refer to a Western guidelines when caring for a patient with a particular Western disease, in order to implement some of their preventive measures, screens, and intervention. Some guidelines are basis for planning, measuring, and comparing how effective treatments are. Whereas, I may use the AAC guidelines if challenged to justify request for insurance reimbursement. AAC guidelines also help give a patient an idea of the time, energy and resource required to address their problem with acupuncture. The caveat is that Western guidelines are based on research that is documented within the protocol itself. While the AAC guidelines do not cite their sources... at least I have not located their process yet. Still, they represent some semblance of "Standard of Care" that insurance companies can understand; and providers can agree upon in a profession with a wide range of treatment styles, methods, and modalities.

 I will soon post the PQRS quality measures and codes that I think TCM practitioners could and should address effectively.

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